ORGANIZING DATA & VALIDATING

Question 1

Also referred to as nursing health history, nursing assessment or database form

Answer 1

ORGANIZING DATA

Question 2

what type of asset format is;
- Gordon’s Functional Health Patterns
- Orem’s Self-Care Model
- Roy’s Adaptation Model

Answer 2

CONCEPTUAL MODELS OR FRAMEWORKS

Question 3

what type of assessment format that Includes factors and attitudes that influence levels of wellness

Answer 3

WELLNESS MODELS

Question 4

what type of assessment format is;
- Body Systems Model
- Maslow’s Hierarchy of Needs
- Developmental Theories

Answer 4

NON - NURSING MODELS

Question 5

The act of “double-checking” or
verifying data to confirm that it is complete, factual and accurate.

Answer 5

VALIDATING DATA

Question 6

subjective or objective data that can be directly observed by the nurse

Answer 6

CUES

Question 7

nurse’s interpretation or conclusions made based on the cues

Answer 7

INFERENCE

Question 8

Recording of client data

Answer 8

DOCUMENTING DATA

Question 9

oral, written or computer-based communication intended to convey information
to others.

Answer 9

REPORT

Question 10

also called chart or client record; a formal legal document that provides evidence of client’s care; can be written or computer
based.

Answer 10

RECORD

Question 11

The process of making an entry on a client record

Answer 11

RECORDING, CHARTING OR DOCUMENTING

Question 12

is accountable and should document according to organization policies and universal standards.

Answer 12

NURSES

Question 13

Time may be recorded in the
conventional manner (12 hour; AM / PM) or according to 24-hour (military) clock

Answer 13

DATE AND TIME

Question 14

Documenting should be done as soon as possible after an assessment or intervention. (Do not document before
assessment or intervention is done)

Answer 14

TIMING

Question 15

Must be legible or easy to read. Hand printing or easily understood handwriting is permissible. (avoid script
or shorthand)

Answer 15

LEGIBILITY

Question 16

Written in “dark ink or permanent pen.”
- For Electronic Records, changes are made in accordance with software
guidelines.

Answer 16

PERMANENCE

Question 17

Use only commonly accepted
abbreviations, symbols, and terms. Refer to approved list given by the institution.

Answer 17

ACCEPTED TERMINOLOGY

Question 18

Incorrect spelling gives a negative impression to the reader and decreases the credibility of the nurse.

Answer 18

CORRECT SPELLING

Question 19

Includes name and title of the nurse.
- For electronic records each nurse has his
or her own code

Answer 19

SIGNATURE

Question 20

Client’s name and identifying
information should be stamped or written on each page of the clinical record. Do not identify charts by room number. Special care is needed when
caring for clients with the same last name

Answer 20

ACCURACY

Question 21

Document events in the order in which they occur.

Answer 21

SEQUENCE

Question 22

Record only information that pertains to client’s health problems and care. Recording irrelevant information may be
considered invasion of client’s privacy and/or libelous.

Answer 22

APPROPRIATENESS

Question 23

Not all data that a nurse obtains about a client can be recorded. However, the
information that is recorded needs to be complete and helpful to the client and
the health care team.

Answer 23

COMPLETENESS

Question 24

Recordings need to be brief as well as complete.
- Client’s name and the word “client” are omitted.
- End each thought with a period.

Answer 24

CONCISENESS

Question 25

Accurate and complete documentation should give legal protection to the nurse,
the health care team, and the institution

Answer 25

LEGAL PRUDENCE