Exam 1 / Part 2 Flashcards
List the domains of learning.
- Cognitive learning is obtaining new information, applying the information, and evaluating the information. For example, cognitive learning takes place when clients learn the signs and symptoms of hypoglycemia and then can verbalize when to notify the provider.
- Affective learning involves feelings, beliefs, and ideals. For example, affective learning takes place when clients learn about the life changes necessary to manage diabetes mellitus and then discuss their feelings about having diabetes.
- Psychomotor learning is gaining skills that require mental and physical activity. For example, psychomotor learning takes place when clients practice preparing insulin injections.
What are the documentation basics?
Documentation includes
- Anything written or printed as proof of patient actions and activities.
- The care provided as documentation or charting; it should reflect the nursing process.
- Vital aspect of nursing practice.
- Information to document: Assessments, Medications, Treatments and responses, and Client education
- They should be factual, accurate, complete, current, organized, nonjudgmental, timely, concise
Information regarding a patient’s health status may not be released to non–health care team members because
A. Legal and ethical obligations require health care providers to keep information strictly confidential.
B. Regulations require health care institutions to document evidence of physical and emotional well-being.
C. Reimbursement issues related to patient care and procedures may be of concern.
D. Fragmentation of nursing and medical care procedures may be identified.
A. Legal and ethical obligations require health care providers to keep information strictly confidential.
Describe two typed of Interdisciplinary Communication Within the Health Care Team.
- Consultations: A professional caregiver giving formal advice to another caregiver
- Referrals: Arrangement for services by another care provider.
List the legal guidelines for documentation.
Correct all errors promptly, using the correct method. Record all facts; do not enter personal opinions. Do not leave blank spaces in nurses’ notes. Write legibly in permanent black ink. If an order was questioned, record that clarification was sought. Chart only for yourself, not for others. Avoid generalizations. Begin each entry with the date/time and end with your signature and title. Keep your computer password secure.
A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record
A. An interpretation of patient behavior.
B. Objective data that are observed.
C. Lengthy entry using lay terminology.
D. Abbreviations familiar to the nurse.
B. Objective data that are observed.
List the methods of recording.
- Paper record: Episode-oriented, Key information may be lost from one episode of care to the next.
- Electronic health record (EHR): A digital version of a patient’s medical record, Integrates all of a patient’s information in one record, Improves continuity of care
- Narrative: The traditional method
- Problem-oriented medical record (POMR): Database, Problem list, Care plan, Progress notes
- Source records: A separate section for each discipline
- Charting by exception (CBE): Focuses on documenting deviations
- Case management plan and critical pathways: Incorporate a multidisciplinary approach to care, Variances
List the types of progress notes (which is a POMR, or problem-oriented medical record).
- SOAP: Subjective, objective, assessment, plan
- SOAPIE: Subjective, objective, assessment, plan, intervention, evaluation
- PIE: Problem, intervention, evaluation
- Focus charting (DAR): Data, action, response
- CBE: Charting by exception
A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of A. PIE documentation. B. SOAP documentation. C. Narrative charting. D. Charting by exception.
C. Narrative charting.
List the Common Record-Keeping Forms.
- Admission nursing history form: Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems
- Flow sheets and graphic records: Help team members quickly see patient trends over time and decrease time spent on writing narrative notes
- Patient care summary or Kardex: A portable “flip-over” file or notebook with patient information
- Standardized care plans: Preprinted, established guidelines used to care for patients who have similar health problems
- Discharge summary forms
- Acuity records
- MARs: Medication Administration Records
When are reports given?
- Hand-off report: Occurs with transfer of patient care; Provides continuity and individualized care; Reports are quick and efficient.
- Telephone reports and orders: Situation-background-assessment-recommendation (SBAR); Document every call; Read back
- Incident or occurrence reports: Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient; Follow agency policy; NOT part of the pt’s medical history
A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to
A. Exchange information among health care members.
B. Provide information about patients from one unit to another unit.
C. Ensure proper care for the patient.
D. Aid in the hospital’s quality improvement program.
D. Aid in the hospital’s quality improvement program.
Which of the following is an accurately written documentation of the effectiveness of a patient’s pain management?
a. Patient is receiving sufficient relief from pain medication.
b. Patient appears comfortable and is resting adequately.
c. Patient reports that on a scale of 1 to 10, his pain is a 3.
d. Patient appears to have a low tolerance for pain and complains frequently about the intensity of his pain.
c. Patient reports that on a scale of 1 to 10, his pain is a 3.
A nurse is preparing information for change of shift report. Which of the following information should the nurse include in the report?
A. The client’s input and output for the shift.
B. The client’s blood pressure from the previous day.
C. A bone scan that is scheduled for today.
D. The medication routine from the medication administration record.
C. A bone scan that is scheduled for today.
A nurse enters a client’s room and finds him sitting in his chair. He states, “I fell in the shower, but I got myself back up and into my chair.” How should the nurse document this in the client’s chart?
A. The client fell in the shower.
B. The client states he fell in the shower and was able to get himself back into his chair.
C. The nurse should not document this information in the chart because she did not witness the fall.
D. The client fell in the shower but is now resting comfortably.
B. The client states he fell in the shower and was able to get himself back into his chair.
