Engage Fundamentals: Professional Nursing: Documentation Flashcards
A patient reports shortness of breath on exertion. What part of the SOAP acronym does this represent?
“S” Subjective
You give the patient a breathing treatment ordered by the Provider. What part of the PIE acronym does this represent?
“I” Intervention.
You go in and check on the patient after they have received their breathing treatment. What part of the PIE acronym does this represent?
“E” Evaluation
Is it okay for an AP to document out of range vitals?
Yes. Each member of the healthcare team is responsible for documenting the data they obtain.
Do providers read and cosign nursing documentation for accuracy?
No.
If a patient requires an OTC medication for nausea relief, is it okay to accept a telephone prescription?
No. This is not an emergent situation. Telephone orders are for emergency situations only.
If a patient required pain control for a terminal condition, is it okay to accept a telephone prescription?
No. This is not an emergent situation.
Is it okay to take a telephone prescription if the Provider is directing a code for an unresponsive patient?
Yes. This is an emergency situation.
What agency advocated for EHRs?
Institute of Medicine.
(T/F) Facilities cannot establish their own rules for documentation methods.
False. Facilities can establish their own rules for documentation methods.
A facility requires staff to only document variations from an exepected set of findings when performing a physical assessment. What documentation method system is being used.
Charting by exception.
Do patient’s have the right to view their medical records at any time?
Yes.
What is the goal of EHRs?
To be able to easily track health information.
Why is the problem-oriented medical record preferred over the source-oriented medical record?
Source-oriented medical records limit sharing information among interdisciplinary team members and can lead to fragmented care.
Problem-oriented medical records are more comprehensive and organized, making it simpler to share with other team members.
