Final 106 Flashcards
What is a guideline for legally sound documentation?
If an order is questioned record that clarification was sought.
Guidelines for documentation and reporting…
Factual, accurate, complete, current and organized.
Method of charting where nurse writes a progress note only when the standardized statement on the form is not met…
Charting by exception, nurse only documents significant findings or exceptions to the predefined norms.
Purposes of the clients medical record include…
Education and research
Nurse instructor helping student with discharge planning and realizes student needs more education when this statement is made…
“I can’t start discharge planning until physician writes discharge order.” This is wrong because discharge planning starts on admission.
What should nurse record as achieved expected outcome?
Client ate 50% of lunch. Clients intake is an outcome.
The type of care management approach that coordinated health care services while streamlining costs?
Case management.
The team member essential for empowering a nursing team?
Clinical nurse specialist.
Case management approach to client care is unique because?
Clinicians oversee the management of clients with specific case types.
Client experiencing anxiety attack, what priority is this?
High priority.
Client that can be assigned to LPN?
The client who had vaginal hysterectomy 2 days ago.
What should NOT be included in discharge summary?
Interventions performed by PT 2 days ago.
When does discharge planning begin?
When client admitted.
Nurse performing admission assessment, after gathering data what is priority?
Orient client to room.
American Nurse Agency
Is not a healthcare regulatory agency.
