Nursing 223: Exam 2 (All Correctly Answered)

What is a medical record? correct answers a confidential, permanent legal document of information relevant to that patients health care What does the health care information system do? correct answers support and enhance health care Define informatics. correct answers use of information and computer technology to support all aspects of nursing practice What does the EMR/EHR do? correct answers increases patient safety What are the five steps of expected documentation? correct answers nursing assessment, care plan, interventions, patient's outcomes or response to care, assessment of patient's ability to manage. Military time: what is 11:42 a.m. and p.m.? correct answers a.m. - 1142 p.m. - 2342 What does SOAP stand for? correct answers subjective-objective-assessement-plan What does PIE stand for? correct answers problem-intervention-evaluation What does DAR stand for? correct answers data-action-response What is charting by exception? correct answers document when something out of the ordinary is observed What are the advantage of using charting by exeption? correct answers easy to track unexpected changes, eliminated repetition and subjective data, decreases time spect on charting Define case managment. correct answers a model of delivering care that includes a multidisciplinary approach What is used to direct and monitor client care and foster identification of variances? correct answers critical pathway What are the 2 types of hand-off report? correct answers change in shift report or a transfer report (move patient to new floor) What communication does a nurse use during a telephone report? correct answers SBAR CHAPTER 21: correct answers