Ch.9

Question 1

Report

Answer 1

An oral or written exchange of information between health care providers

Question 2

Confidentiality

Answer 2

Information about patients provided only to appropriate personnel

Question 3

Record

Answer 3

Permanent written communication with patient’s health care management

Question 4

POMR

Answer 4

structured method documentation with emphasis on the patients problems

Question 5

Acuity recording

Answer 5

Documentation that requires staff to identify interventions and allows patients to be compared with one another

Question 6

Standards for health care agencies and documentation are set by:

Answer 6

The Joint commission

Question 7

Identify 5 characteristics of quality documentation:

Answer 7

Factual,accurate,complete, current, organized.

Question 8

SBAR

Answer 8

Situation, background, assessment, recommendation

Question 9

Completion of narrative notes only when there are abnormal patient findings is part of the concept of what:

Answer 9

“charting by exception”

Question 10

Identify the four concepts of informatics:

Answer 10

1. data
2. information
3. knowledge
4. wisdom

Question 11

SOAP

Answer 11

Subjective, Objective, Assessment, plan

Question 12

PIE

Answer 12

Problem, intervention, evaluation

Question 13

DAR

Answer 13

data, action, response.