OTHER SOURCES OF CLIENT

Question 1

it is a medical info held about an individual patient. It includes info related to their past and current health or illness, their treatment history, lifestyle choices and genetic data

Answer 1

Clients data

Question 2

data obtained from the patient herself

Answer 2

Primary Source

Question 3

data include info from the patient’s chart, fam mem, or other health care team members.

Answer 3

Secondary sources

Question 4

is a complete and total record of a patient’s clinical data and medical history

Answer 4

Clients chart

Question 5

“Requires client record to be timely, complete, accurate, confidential and specific to the client.”

Answer 5

Jcaho

Question 6

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

Answer 6

ANA (American Nurses Association) code of ethics

Question 7

“Accurate documentation of actions and outcomes of delivered care is the hallmark of nursing accountability.”

Answer 7

Code of ethics for filipino nurses

Question 8

is a federal law that requires the creation of
national standards to protect sensitive patient health information from being disclosed.

Answer 8

Health Insurance Portability and Accountability Act of 1996

Question 9

to provide continuity of care which means documenting services, so others have a source upon which to base care.

Answer 9

PRIMARY PURPOSE OF CLIENT RECORDS

Question 10

Prevents fragmentation, repetition and delays in client care as it is used by health care professionals in communicated with each other and with the client.
.

Answer 10

Communication

Question 11

Review client records for quality assurance to determine if the hospital is meeting its stated standards.

Answer 11

Auditing Health Agencies

Question 12

Data in the record can be used for nursing research. Treatment plans for several clients with the same health problems can yield information helpful in treating other clients.

Answer 12

Research

Question 13

Client records may use data as educational tools.

Answer 13

Education

Question 14

Client’s records serve as evidence in court. Admissible in court as evidence unless client objects
because information client gives to primary care provider is confidential.

Answer 14

Legal Document

Question 15

Records may help health care planners identify agency needs, such as overuse or underuse of
hospital services.

Answer 15

Health Care Analysis

Question 16

What are the key elements of a client’s medical chart

Answer 16

• Patient Demographics
• Financial Info
• Consent and authorization forms
• Medical History
• Nursing Records
• Diagnostic Procedures and lab results
• Operative and Anesthesiology Report
• Discharge Summary

Question 17

• Assignment of benefits: the patient or guarantor authorizes their health insurance company to make payments directly to the physician, medical practice, or hospital for the treatment received.

Answer 17

Financial Information

Question 18

Filled out by the patient on their first visit to the doctor’s office and updated as needed.
It contains information that is directly related to the patient, such as their last name, first name, gender, DOB, marital status, address, telephone number, employment status, employer’s address and phone number, and
name and contact information for the person who is responsible for them.

Answer 18

Patient Demographics

Question 19

it is a signed statement from the patient or guardian approving the course of treatment.

Answer 19

Consent and Authorization Forms

Question 20

This document outlines any medical ailments the patient has had in the past and present.

Answer 20

Medical History

Question 21

In these records, vital indicators including blood pressure, temperature, pulse, respiration, intake, output, etc of the patient are recorded.

Answer 21

Nursing Records

Question 22

include new information and changes during patient treatment.

Answer 22

Progress Notes

Question 23

Prescribed medication including dose, method of intake, and schedule.

Answer 23

Medication List

Question 24

These comprise documents containing the findings of every diagnostic test and laboratory procedure that the patient underwent.

Answer 24

Diagnostic Procedures and Lab results

Question 25

Surgeon’s written account of the process, including the preoperative and postoperative diagnoses, the precise specifics of the surgical procedure, the patient’s response to it, and any complications that may have arisen

Answer 25

Operative and Anesthesiology Report

Question 26

A summary of the patient’s hospital care, including the date of admission, the diagnosis, the course of treatment and any responses from the patient, the outcomes of the tests, the final diagnosis, the follow-up plans, and the date of discharge.

Answer 26

Discharge Summary

Question 27

Physician’sordersforthepatienttoreceivetesting,procedures,orsurgeryincludingdirectionstoother
treatment team members.

Answer 27

Doctors Order Sheet

Question 28

What is the 2 nurses responsibility?

Answer 28

• Ensure that records are accurate and complete to effectively manage the client and allow for good communication between the nurse and other healthcare members.
• Keeping good nursing records allows for identifying problems that have arisen and the action is taken to rectify them.

Question 29

A variety of paper or electronic forms are available for the type of information nurses routinely document.

Answer 29

Common Record Keeping forms

Question 30

a nursing history form when a patient is admitted to a nursing unit.

The form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems.

Answer 30

Admission Nursing Forms

Question 31

allow you to quickly and easily enter assessment data about a patient. It helps team members quickly see patient trends over time and decrease time spent on writing narrative
notes.

Answer 31

Flow Sheets and Graphic Records

Question 32

• Concise method of organizing and recording data
• Series of cards kept in a portable index file or on computer-generated form.
• Information quickly accessible
• Pertinent information about the client arranged in sections.

Answer 32

Kardex

Question 33

• Made by nurses.
• Provide information about the progress a client is making toward achieving desired outcomes.
• Include information about client problems and nursing interventions.

Answer 33

Nurses Progress Notes

Question 34

• Completed when client discharged - terms that can be readily understood.
• Completed when client transferred to another institution.
• Include some or all the following: Description of client’s physical, mental, and emotional status, resolved health
problems, Treatments to be continued, Current medications, include restrictions that relate to activity, diet, and bathing, Functional/self-care abilities, Comfort level, Support networks, Client education, Discharge destination, Referral services.

Answer 34

Discharge Summary Form

Question 35

REMEMBER

Answer 35

“What is not written, is not done”