NUR 116 - Week 9 - Documentation Flashcards
1
Q
Identify the purpose and components of the health record.
A
2
Q
Discuss the types of documentation in a health record.
A
Source-oriented medical records
Problem-oriented medical records
Subjective, objective, assessment and plan charting (SOAP)
Problem-Intervention-Evaluation charting (PIE model)
Focus charting
Charting by Exception (CBE)
3
Q
Discuss guidelines for accurate documentation in a health record.
A
4
Q
Explore legal considerations related to documentation in a health record.
A
5
Q
A
6
Q
When attempting to administer a 10 p.m. sleeping medication, the nurse assesses that the patient appears to be asleep. Which should the nurse do?
A
7
Q
A
