Documentation

Question 1

HIPAA is mandatory

Answer 1

a personal password, logging computers out, displaying info on monitor for others to see, shredding unneeded docs, correcting an entry error, sensitive material, info technology

Question 2

SOAP note

Answer 2

subective -what client says
objective - observed by use of senses
assessment - interpretation
plan
VARIATION:
I - intervention
E - evaluation
R - revision

Question 3

Charting by exception

Answer 3

documentation system in which only abnormal or significant findings or exceptions are recorded

Question 4

highlighted med on MAR

Answer 4

discontinued med

Question 5

POMR

Answer 5

problem-oriented medical record - data organized by problem rather than source of info (helps collaboration and alerting the client’s needs)

Question 6

problem list

Answer 6

listed in the order in which they are identified, we write as nursing Dx whereas doctors write as med Dx, surgical procedures or symptoms (may be redefined)

Question 7

progress note

Answer 7

entry by all h.c. professionals of care noted in POMR - SOAP note

Question 8

PIE

Answer 8

Documentation model:
problems
interventions
evaluation

Question 9

DAR

Answer 9

data - assessment
action - planning and implementation
response - evaluation

Question 10

3 components of charting by exception

Answer 10

flow sheets
standards of nursing
care