Exam 2 - Documentations

Question 1

paper record-episode oriented

Answer 1

something happened thats why youre documenting

Question 2

electronic health record

Answer 2

• a digital version of pt medical record
• to share with other departments
• improves continuity of care

Question 3

Which one integrats all of p info into 1?

Answer 3

ehr

Question 4

narrative

Answer 4

the traditional method

Question 5

problem-oriented medical record

Answer 5

• database
• problem list
• care plan
• progress note

Question 6

source records

Answer 6

a separate section for each discipline

Question 7

charting by exception

Answer 7

focuses on documenting deviation

Question 8

case management plan and critical pathways

Answer 8

incorporate a multidisciplinary approach to care

• variance
• manage and make sure insurance, medicare, and medicaid are all on task and on time

Question 9

2 designs of NISs

Answer 9

• nursing process design

- protocol or critical pathway design

Question 10

flow chart

Answer 10

shows trends in vital signs, blood glucose levels, pain level, and other frequent assessments

Question 11

narrative documentation

Answer 11

records information as a sequence of events in story-like manner

Question 12

charting by exceptions

Answer 12

uses standardized forms that identify norms and allows selective documentation of deviation from these norms