Chapter 26 Flashcards

0
Q

To eliminate Barriers that could cause delay, health care providers are

A

1: required to notify patients of their privacy policy
2: make a reasonable effort to obtain written acknowledgement of this notification

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1
Q

Documentation

A

Anything written or printed which you rely on as a record or proof of patients actions

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2
Q

The joint commission standards of documentation require

A

That all patients admitted to a facility have an assessment of physical, psychosocial, environmental, self-care, knowledge level and discharge planning needs

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3
Q

Diagnosis-related group

A

Classification system based on patient’s medical diagnoses and supports reimbursement

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4
Q

Education

A

Education of a patient is critical. The patient care record tells the nature of their illness and the response to it

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5
Q

Research

A

Using patient’s records for medical research studies to bring about evidence-based practice

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6
Q

Auditing

A

Reviews the financial charges and determines the degree to which standards of care are met

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7
Q

Guidelines for quality documentation and reporting

A
Factual
Accurate
Complete
Current
Organized
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8
Q

Problem-oriented medical record

A

Emphasizes patient problems

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9
Q

Narrative

A

Story-like format that is repetitious and time consuming

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10
Q

SOAP

A

Subjective-Objective-assessment-plan

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11
Q

SOAPIE

A

Subjective- objective-assessment-plan-intervention-evaluation: similar to the nursing process

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12
Q

PIE

A

Problem-intervention-evaluation: unifies the care plan and progress notes

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13
Q

Focus charting

A

DAta Action Response: follows nursing process and incorporates all aspects of the nursing process

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14
Q

Electronic health record

A

Record of patient health information generated whenever they enter a health care delivery setting

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15
Q

Source record

A

Separate sections for organizing a patient’s chart.

16
Q

Case management

A

Incorporates an interdisciplinary approach when documenting.

17
Q

Critical pathways

A

Interdisciplinary care plans that include problems, interventions and expected outcomes

18
Q

Admission nursing history forms

A

Guides the nurse through a complete assessment to identify relevant problems and diagnoses

19
Q

Flow sheets

A

Allows quick and easy entering of assessment data. Help team members to quickly find trends over time.

20
Q

Kardex

A

A portable flip notebook. Organizing information for quick access.

21
Q

Acuity records

A

Determined by a computer based on the type and number of nursing interactions over 24-hours

22
Q

Standardized care plans

A

Established guidelines for who to care for all patients with similar problems.

23
Q

Discharge summary forms

A

Plan for home care, support and equipment necessary to leave.

24
Q

What to include in a hand-off report

A
Provide essential background information
Identify nursing diagnoses
Describe objective measurements
Share information about family members when in relation to the problem
Continuously review discharge plans
Relay significant changes in condition
Evaluate the results
Be clear about priorities.
25
Q

What to document when giving a TO

A

When, who called, who was called, what info was given, what was received and verification of the information by the healthcare provider.

26
Q

Guidelines for TO AND VO

A
Clearly determine the name, room number and diagnosis
Use clarification questions
Write them down
Follow agency policy
Health care provider co-signature
27
Q

Health informatics

A

Te application of computer and information science and applied biomedical science to facilitate data

28
Q

Nursing informatics integrates

A

Nursing science, computer and information science

29
Q

Two nursing information systems

A

Clinical information systems

Administrative information systems

30
Q

Advantages in nursing information system

A
Increased spending time with patients
Reduced errors
Reduced hospital costs
Better access to information
Better quality documentation.