Documentation

Question 1

Informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem.

Answer 1

Discussion

Question 2

Is oral, written or computer-based communication intended to convey information to others.

Answer 2

Report

Question 3

Formal, legal document that provides evidence of a client’s care

Answer 3

Chart/Client Record

Question 4

Recording a.k.a?

Answer 4

charting/ documenting

Question 5

Process of making an entry on a client record

Answer 5

Recording

Question 6

Purposes of Records

Answer 6

• Communication
• Planning client care (NCP)
• Auditing health agencies
• Research
• Education
• Reimbursement
• Legal Documentation
• Healthcare analysis

Question 7

A traditional part of source-oriented record

Answer 7

Narrative Charting

Question 8

it consists of written notes that include routine care, normal findings and client problems

Answer 8

narrative charting

Question 9

ROM =

Answer 9

range of motion

Question 10

Intended to make the client and client concerns the focus of care

Answer 10

Focus Charting

Question 11

Provides a holistic perspective of the client and the client’s needs

Answer 11

Focus Charting

Question 12

May be a condition, a nursing diagnosis, a behavior, a sign or symptom, an acute change in the client’s condition, or client’s strength

Answer 12

Focus

Question 13

Reflects the assessment phase of the nursing process and consists of observations of client status and behaviors

Answer 13

Data

Question 14

Reflects planning and implementation\ and includes immediate and future nursing actions

Answer 14

Action

Question 15

Reflects the evaluation phase of the nursing process and describes the client’s response to any nursing and medical care

Answer 15

Response

Question 16

FDAR meaing

Answer 16

Fcous, Data, Action. Response

Question 17

Consists of information obtained from what the client says. It describes the client‘s perceptions and experience with the problem

Answer 17

Subjective Data

Question 18

Consists of information that is measure or observed by use of the senses

Answer 18

Objective Data

Question 19

Interpretations or conclusions drawn about the subjective and objective data; initially, it is the statement of the
problem

Answer 19

Assessment

Question 20

it should describe the client’s condition and level of progress

Answer 20

Evaluation

Question 21

The plan of care designed to resolve the stated problem

Answer 21

Plan

Question 22

Refer to the specific interventions that has been performed by the caregiver

Answer 22

Interventions

Question 23

Includes client’s responses to nursing interventions and medical treatments. This is primarily reassessment data.

Answer 23

Evaluation

Question 24

reflects care plan modification suggested by the evaluation

Answer 24

Revision