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FUNDA > DOCUMENTING > Flashcards

DOCUMENTING Flashcards

1
Q

an informal oral consideration of a subject by two or more health care personnel to identify a problem

A

DISCUSSION

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2
Q

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

A

REPORT

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3
Q

only a written/computer based

A

RECORD

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4
Q

recording is also called

A

charting or documenting

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5
Q

is the process of making an entry on a client record

A

RECORDING

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6
Q

clinical record is also called

A

chart/client record

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7
Q

It is a formal, legal document that provides evidence of a client’s care

A

CLINICAL RECORD

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8
Q

The nurse has a duty to maintain _____ of all patient information”

A

confidentiality

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9
Q

Access to the record is ____ to health professionals involved in giving care to the client

A

restricted

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10
Q

who is the rightful owner of the client’s record

A

The institution or agency

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11
Q

purpose of client records

A

Communication
Planning client care
Auditing Health Agencies
Research
Education
Reimbursement
Legal Documentation
Health Care Analysis

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12
Q

the traditional client record each person or department makes notations in a separate section/s of the client’s record

A

SOURCE-ORIENTED RECORD

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13
Q

example of source oriented record

A

the admission dept. – Admission sheet

the physician – Doctor’s order sheet

A physician’s history sheet

Progress notes

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14
Q

the traditional part of the source-oriented record

A

Narrative Charting

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15
Q

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

A

Narrative Charting

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16
Q

meaning of POMR

A

PROBLEM-ORIENTED MEDICAL RECORD

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17
Q

who established POMR

A

Lawrence Weed

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18
Q

what record in which the data arranged according to the problems the client has rather than the source of the information

A

POMR

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19
Q

4 COMPONENTS OF POMR

A

Database

Problem List

Plan of Care

Progress Notes

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20
Q

FORMATS OF PROGRESS NOTES

A

SOAP, SOAPIE/SOAPIER ; PIE

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21
Q

meaning of SOAP

A

subjective
objective
analysis
planning

22
Q

SOAPIE/SOAPIER means what

A

subjective
objective
analysis
planning
intervention
evaluation
revision

23
Q

meaning of PIE

A

problem
intervention
evaluation

24
Q

consists of all information known about the client when the client first enters the health Care agency

A

Database

25
Q

problems are listed in the order in which they are identified, and the list is continually updated as new problems are identified and others are resolved

A

Problem List

26
Q

the initial list of orders made with reference to the active problems.

A

Plan of Care

27
Q

advantage sa pomr

A

encourage collaboration

alerts caregivers to clients needs; easier to track problems

28
Q

disadvantages of pomr

A

caregivers ability to use charting format

takes constant vigilance to maintane an up to date list

inefficient (assessments & interventions are repeated)

29
Q

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

A

FOCUS CHARTING

30
Q

recrding in focus charting consist of

A

date and time

focus

progress notes

31
Q

which charting utilizes DAR

A

focus charting

32
Q

meaning of DAR

A

data, action and response

33
Q

a documentation system in which only abnormal or significant findings or exceptions to norms are recorded.

A

CHARTING BY EXCEPTION

34
Q

3 elements of charting by exception

A

flow sheets

standard of nursing care

bedside access to chart forms

35
Q

like graphic record, fluid balance record, daily nursing assessment record, client teaching record, client discharge record and skin assessment record

A

Flow sheets

36
Q

are being developed as a way to manage the huge volume of information required in contemporary health care

A

COMPUTERIZED DOCUMENTATION

37
Q

emphasizes quality, cost-effective care delivered within an established length of stay

A

CASE MANAGEMENT

38
Q

Uses a multidisciplinary
approach to planning
and documenting
client care, using
critical pathways.

A

CASE MANAGEMENT

39
Q

DOCUMENTING NURSING ACTIVITIES:

A
  1. Admission Nursing Assessment
  2. Nursing Care Plans
  3. Kardexes
  4. Flow Sheets
  5. Progress Notes
40
Q

also referred to as an initial database, nursing history, or nursing assessment, is completed when the client is admitted to the nursing unit

A

Admission Nursing Assessment

41
Q

2 TYPES OF NURSING CARE PLANS

A

traditional
standardized

42
Q

a care plan that is written for each client. Mostly, it has 3 columns: nsg. diagnosis, expected outcomes, and nsg. interventions

A

traditional

43
Q

care plan that was developed to save documentation time.

A

standardized

44
Q

a widely used, concise method of organizing and recording data about a client ;consists of a series of cards kept in a portable index file or on a computer-generated forms.

A

Kardexes

45
Q

made by nurses to provide information about the progress a client is making toward achieving desired outcomes.

A

Progress Notes

46
Q

GENERAL GUIDELINES FOR RECORDING

A

Date and Time
Timing
Legibility
Permanence
Accepted Terminology
Correct Spelling
Signature
Accuracy
Sequence
Appropriateness
Completeness
Conciseness
Legal prudence

47
Q

purpose of reporting

A

to communicate specific information to a person or group of people

48
Q

is given to all nurses on the next shift.
Its purpose is to provide continuity of care

A

Change-of-Shift Reports

49
Q

reports done through telephone

A

Telephone Reports

50
Q

orders made by physicians through telephone.
Transcribed onto the physician’s order sheet and should be counter signed within 24 hours by the physician who made the order

A

Telephone Orders

51
Q

is a meeting of a group of nurses to discuss possible solutions to certain problems of a client.

A

Care Plan Conference

52
Q

are procedures in which two or more nurses visit selected clients at each client’s bedside.

A

Nursing Rounds

FUNDA (16 decks)

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