Documentation (Chap 20) Flashcards
*Quality process review recognizes that _____________ is the primary source of evidence used to continuously measure performance outcomes against predetermined standards.
documentation
*The purposes of patient records include reimbursement, communication, diagnostic and therapeutic orders, research, decision analysis, quality process and performance improvement, education, care planning, and providing a legal source of documentation.
A. True
B. False
TRUE
*Computer-based records, or ____________ health records (EHRs), allow data to be distributed among many caregivers in a standardized format.
electronic
*In a source-oriented record, nurses include information to inform caregivers of achievement toward patient goals in a narrative format called a ___________ note.
progress
*When receiving a verbal order, the registered professional nurse should ask for a “read-back” from the medical provider.
A. True
B. False
FALSE
*Student nurses should never use their cellphone or conduct personal business on a computer in the clinical setting.
A. True
B. False
TRUE
*An example of a helpful and accurate nursing note is: “The patient appears to be resting more comfortably today than yesterday.”
A. True
B. False
FALSE
*Charting by ____________ is a shorthand documentation method in which only deviations from well-defined standards of practice are documented in narrative notes.
exception
*All patient information written, saved on a computer, or spoken aloud is considered private or confidential.
A. True
B. False
TRUE
*The __________________record is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.
graphic
