Implementation

Question 1

What are the three skills in implementation?

Answer 1

Cognitive Skills (Intellectual Skills)
Interpersonal Skills
Technical Skills

Question 2

What are the four cognitive skills?

Answer 2

Problem Solving
Decision Making
Critical Thinking
Creativity

Question 3

What is the process of implementing?

Answer 3

Reassing the client
Determining nurse need for assistance
Implementing nurse intervention
Supervising delegated care
Documenting nursing activities

Question 4

Transfer of responsibility from one person to another while retaining accountability for the outcomes

Answer 4

Delegation

Question 5

Downward/transfer of both the responsibility and accountability of _ from one individual to another

Answer 5

assignment

Question 6

What is the responsibility of the nurse in delegation and assignment?

Answer 6

Appropriate delegation of duties
Adequate supervision or assigned

Question 7

Evaluation is composed of:

Answer 7

documenting responses to interventions
evaluating the effectiveness of interventions
evaluating outcome achievement
reviewing the nursing care plan

Question 8

Measure used to maintain confidence and secure components of client records

Answer 8

documentation

Question 9

What is essential to the goal of client care?

Answer 9

Effective communication among health professionals

Question 10

Health personnel communicate through?

Answer 10

discussion
reports
records

Question 11

as informal oral consideration of a subject by two or more healthcare personnel to identify a problem or establish strategies to resolve a problem.

Answer 11

discussion

Question 12

is a formal, legal document that provides evidence of a client’s care and can be written or computer based.

Answer 12

record/chart/client record

Question 13

The process of making an entry on a client record is called

Answer 13

recording, charting, or documenting.

Question 14

the The Joint Commission requires client record documentation to be

Answer 14

A-ccurate
C-omplete
C-onfidential
T-imely
S-pecific

Question 15

Health care reform has been pivotal in the process of increasing the use of the

Answer 15

electronic health record

Question 16

states that “ ..the nurse has a duty to maintain confidentiality of all patient information”

Answer 16

The American Nurses Association Code of Ethics (2001)

Question 17

is the rightful owner of the client record.

Answer 17

institution or agency

Question 18

Changes in the laws regarding client privacy became effective on

Answer 18

April 14, 2003

Question 19

HIPAA

Answer 19

Health Insurance Portability and Accountability Act of 1996

Question 20

HIPAA

Answer 20

Health Insurance Portability and Accountability Act of 1996

Question 21

The new HIPAA regulations maintain the privacy and confidentiality of

Answer 21

Protected Health Information

Question 22

is identifiable health information that is transmitted or maintained in any form or medium, including verbal discussions, electronic communications with or about clients, and written communications

Answer 22

Protected Health Information

Question 23

is identifiable health information that is transmitted or maintained in any form or medium, including verbal discussions, electronic communications with or about clients, and written communications

Answer 23

PHI

Question 24

Security Rule of HIPAA became mandatory in

Answer 24

2005

Question 25

This rule governs the security of electronic PHI.

Answer 25

Security Rule of HIPAA in 2005

Question 26

What are the purpose of client’s records?

Answer 26

communication
planning client care
auditing health agencies
research
education
reimbursement
legal documentation
health care analysis

Question 27

Communication of client’s records prevents

Answer 27

fragmentations
repution
delays in client care

Question 28

Nurses use ________ to evaluate the effectiveness of the nursing care plan.

Answer 28

baseline or ongoing data

Question 29

is a review of client records for quality assurance purposes

Answer 29

audit

Question 30

Who reviews the client records to determine if a particular health agency is meeting its stated standards

Answer 30

The Joint Commission

Question 31

The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients.

Answer 31

Research

Question 32

For a facility to obtain payment through Medicare, the client’s clinical record must contain the

Answer 32

correct diagnosis related group codes

Question 33

are supported by accurate, thorough recording by nurses.

Answer 33

codable diagnoses such as DRGs

Question 34

Client’s record is ________ and is usually admissible in court as evidence

Answer 34

legal document

Question 35

What are the different Documentation Systems?

Answer 35

the source-oriented record
problem-oriented Medical record
PIE model (problems, intervention, evaluation)
focus charting
CBE (Charting by exception)
Computerized documentation
Case Management

Question 36

is a traditional part of the source-oriented.

Answer 36

Narrative Charting

Question 37

Narrative recording is replaced by

Answer 37

Charting by exception
Focus Charting

Question 38

POMR or Problem Oriented Medical Record was established by?

Answer 38

Lawrence Weed in 1960

Question 39

the data are arranged according to the problems the client has rather than the source of the information.

Answer 39

POMR-Problem Oriented Medical Record

Question 40

What are the advantages of POMR?

Answer 40

1. it encourage collaboration
2. the problem list in the front of the chart alerts caregivers to the client’s needs and makes it easier to track the status of each problem

Question 41

all information known about the client when the client first enters the health care agency.

Answer 41

database

Question 42

Database includes

Answer 42

nursing assessment
primary care provider’s history
social and family data
results of the physical examination and diagnostic test

Question 43

is derived from the database.

Answer 43

problem list

Question 44

are generated by the individual who lists the problems

Answer 44

care plans

Question 45

is a chart entry made by all health professionals involved in a client’s care; they all use the same type of sheet for notes.

Answer 45

progress notes in the PO

Question 46

How can you get the objective data?

Answer 46

IPPA
Vital Signs
Labs and diagnostic results

Question 47

is the interpretation or conclusions drawn about the subjective and objective data.

Answer 47

Assessment

Question 48

This system consists of a client care assessment flow sheet and progress notes.

Answer 48

Pie model

Question 49

describes the patient’s perspective and focuses on documenting the patient’s current status, progress towards goals and response to interventions.

Answer 49

Focus Charting

Question 50

provides a holistic perspective of the client and the client’s needs.

Answer 50

Focus charting system

Question 51

Focus charting system provides

Answer 51

nursing process framework for progress notes

Question 52

For focus charting, in the eight hours shift, use ____ for morning and afternoon shift and ____ for night shift

Answer 52

blue or black ink for morning and afternoon shift
red ink for night shift

Question 53

What are the different nursing interventions in the focus charting?

Answer 53

independent
basic
perspective

Question 54

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

Answer 54

Charting by exception

Question 55

Charting by exception incorporates three key elements, what are these?

Answer 55

Flow sheets
Standards of nursing care
Bedside Access to chart forms

Question 56

is a widely used, concise method of organizing and recording data about a client, making information quickly accessible to all health professionals.

Answer 56

The Kardex

Question 57

enables nurses to record nursing data quickly and concisely and provides an easy to-read record of the client’s condition over time,

Answer 57

Flow Sheet

Question 58

This record typically indicates body temperature, pulse, respiratory rate, blood pressure, weight, and, in some agencies, other significant clinical data such as admission or postoperative day, bowel movements, appetite, and activity.

Answer 58

Graphic Record

Question 59

All routes of fluid intake and all routes of fluid loss

Answer 59

Intake and output record

Question 60

Medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route, and the nurse’s signature.

Answer 60

Medication Administration Record

Question 61

are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required.

Answer 61

Discharge note and referral summary