Ch 26 Flashcards
0
Q
Each entry in a pts records ends with:
A
A caregivers full name or initials and status
1
Q
What are the basis for establishing reimbursement for patient care
A
Diagnosis-related groups (DRGs)
2
Q
What’s is a method of documentation that emphasizes a PTs problem?
A
Problem-oriented medical record (POMR)
3
Q
What does SOAP start for and when do you use it?
A
Subjective data (verbalizations of the PT) Objective data (that which is measured and observed) Assent (diagnosis based on the data) Plan (what the caregiver plans to do) Use SOAP when charting
4
Q
What does PIE stand for
A
Plan
Intervention
Evaluation
5
Q
What does DAR stand for
A
Data
Action
Evaluation
6
Q
What is a flip-over file called and where is it kept?
A
Kardex which is a quick reference of the PT, found at the nurses station
7
Q
What should the nurse do after she receives a telephone or verbal order?
A
They should read the order back to the health care provider
