Chapter 26

Question 1

Documentation

Answer 1

Is a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions, and patient responses In a health record

Question 2

What is reimbursement?

Answer 2

Documentation by all members of the healthcare team is used to determine the severity of illness, the intensity of services received, and the quality of care provided during an episode of care. Insurance companies use this information to determine payment or reimbursement for healthcare services

Question 3

Hi tech

Answer 3

Establish provisions to promote the meaningful use of health information technology to improve the quality and value of healthcare

Question 4

Confidentiality

Answer 4

1. Nurses are legally and ethically obligated to keep all patients information confidential
2. Nurses are responsible for protecting records from all unauthorized readers
3. HIPPA Requires that disclosure or request regarding health information be limited to the minimum necessary

Question 5

What are the guidelines for quality documentation?

Answer 5

Factual, accurate, complete, current, and organized

Question 6

What does it mean by factual?

Answer 6

A factual record contains descriptive objective information about what a nurse observes, hears, palpates and smells

Question 7

What is accurate information when documenting??

Answer 7

The use of exact measurements establishes accuracy and help you determine if a patient’s condition has changed in a positive or negative way. For example, a description such as “intake, 360 mL of water” is more accurate than “drinking enough”

Question 8

Describe complete documentation

Answer 8

You need to ensure that the information within a recordEd. Entry or a report is complete, containing appropriate in essential information.

Question 9

What is current documentation

Answer 9

Timely entries are essential in a patient’s ongoing care. Delays in documentation leas too and unsafe patient care.

Question 10

How do you keep documentation is organized?

Answer 10

Information entered into a medical record facilitate communication when is documented in a logical order

Question 11

What are the four types of progress notes?

Answer 11

Soapie, soap, pie, Dar

Question 12

Soapie-

Answer 12

Subjective, objective, assessment, plan, intervention, evaluation

Question 13

Soap

Answer 13

Subjective, objective, assessment, plan

Question 14

Pie

Answer 14

Problem, intervention, evaluation

Question 15

Dad

Answer 15

Data, action, response

Question 16

What is the problem oriented medical record?

Answer 16

A system of organizing documentation to place the primary focus on patients individual problems

Question 17

What is in acuity rating system?

Answer 17

To determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours

Question 18

What does the acuity rating system depend on

Answer 18

Based on type and number of nursing interventions required by a patient over a 24 hour.
Classification used to compare one or more patients to another group of patients

Question 19

Nursing informatics

Answer 19

The use of information and a computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research