*Pro. Nursing DOCUMENTATION Flashcards
ABD
abdomen
CBC
Complete Blood Count
C&S
Culture and Sensitivity
EHR
Electronic Health Record
CPOE
Computerized Provider Order Entry
A nurse is discussing legal regulation regarding medical records with a newly hired AP. Which information should the nurse include?
Facilities can establish their own rules for documentation
Charting by exception
only chart unexpected findings
Sub. Obj. Assessment, Plan format
SOAP problem oriented record
Problem intervention evaluation model
PIE model is the focus is on nursing process.
Data, action, response charting
DAR charting. focus charting on a specific problem
Electronic documentation helps with?
Reduce medical errors
makes client medical history
increase accuracy of coding procedures
A nurse is discussing problem oriented medical records with a group of new nurses. Which info should the nurse include?
A problem oriented medical record promotes information sharing among members of interdisciplinary team.
who can access clients chart on the unit?
Admitting provider
charge nurse on the unit
the client
Who started EHR?
The institute of Medicine