DOCUMENTATION

Question 1

an 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

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

Answer 2

report

Question 3

it is a formal, legal document that provides evidence of a client’s care and can be written or computer based

Answer 3

record/chart/client record

Question 4

the process of making an entry on a client record is called

Answer 4

reporting/charting/documenting

Question 5

the client’s record is protected legally ; it is a _ record

Answer 5

private

Question 6

__ is the rightful owner of the client’s record

Answer 6

institution or agency

Question 7

the student or health professional must protect the client’s privacy by not using a __ or __ that would identify the client

Answer 7

name or any statement

Question 8

the traditional client record is a _ record ; notations in a separate section or sections of the client’s chart

Answer 8

source-oriented record

Question 9

traditional part of the source-oriented record ; consists of written notes that include routine care, normal findings, and client problems ; no right or wrong order to the information, just chronological

Answer 9

narrative charting

Question 10

who established the problem oriented medical record

Answer 10

lawrence weed

Question 11

record that encourages collaboration and problem list in the front of the chart alerts caregivers to the client’s needs and makes it easier to track the status of each problem

Answer 11

POMR

Question 12

consists of all information known about the client when the client first enter the health care agency

Answer 12

database

Question 13

derived from database ; kept at the front of the chart and serves as index to the numbered entries in the progress notes

Answer 13

problem list

Question 14

is a chart entry made by all health professionals involved in a client’s care

Answer 14

progress note

Question 15

it is where the statement of the problem should be ; description of the client’s condition and level of progress

Answer 15

assessment

Question 16

it is primarily the reassessment data

Answer 16

evaluation

Question 17

intended to make the client and client concerns and strengths focus of care

Answer 17

focus charting

Question 18

meaning of FDAR

Answer 18

focus
data
action
response

Question 19

in fdar, it reflects the planning and implementation ; immediate and future nursing action ; changes on the plan of care

Answer 19

action

Question 20

in fdar, it reflects the evaluation phase of the nursing process

Answer 20

response

Question 21

used to manage the huge volume of information required in contemporary health care

Answer 21

EHR

Question 22

it emphasizes quality, cost-effective care delivered within an established length of stay ; uses a multidisciplinary approach to planing and documenting

Answer 22

case management

Question 23

a goal that is not met is called a__ ; deviation from what was planned on the critical pathway

Answer 23

variance

Question 24

it should describe the client’s ongoing status and reflect the full range of the nursing process

Answer 24

client record

Question 25

it is completed when the client is admitted to the nursing unit

Answer 25

initial database/nursing history/assessment

Question 26

two types of nursing care plans

Answer 26

traditional and standardized

Question 27

developed to save documentation time

Answer 27

standardized

Question 28

widely used, concise method ; makes information quickly accessible to all health professionals

Answer 28

kardex

Question 29

employs a stuctured, logical format ; SOAP, SOAPIE, SOPIER

Answer 29

problem oriented medical record

Question 30

use of a column format to chart data, action and response

Answer 30

focus charting

Question 31

communication tool that provides a method of clearly communicating the pertinent information

Answer 31

ISBARR

Question 32

these reports happen any time one health care provider transfers care of a patient to another healthcare provider ; to provide better continuity

Answer 32

handoff reports

Question 33

two types of handoff reports

Answer 33

change of shift
transfer report

Question 34

is given to all nurses on to the next shift ; up to date information about patient’s condition

Answer 34

change of shift report

Question 35

given whenever the patient is transferred to other health care unit ; nursing to nursing

Answer 35

transfer report

Question 36

health professionals frequently report about a client by telephone

Answer 36

telephone reports

Question 37

occurs when a healthcare provider gives an order over the phone to a registered nurse

Answer 37

telephone order

Question 38

involves the healthcare provider giving orders to a nurse while they are standing near each other

Answer 38

verbal order

Question 39

they usually occur at night or during emergencies and frequently causes medical errors

Answer 39

telephone order
verbal order

Question 40

any event that is not consistent with the routine operation of a healthcare unit or routine care of a patient

Answer 40

incident or occurrence reports