*Pro. Nursing DOCUMENTATION

Question 1

ABD

Answer 1

abdomen

Question 2

CBC

Answer 2

Complete Blood Count

Question 3

C&S

Answer 3

Culture and Sensitivity

Question 4

EHR

Answer 4

Electronic Health Record

Question 5

CPOE

Answer 5

Computerized Provider Order Entry

Question 6

A nurse is discussing legal regulation regarding medical records with a newly hired AP. Which information should the nurse include?

Answer 6

Facilities can establish their own rules for documentation

Question 7

Charting by exception

Answer 7

only chart unexpected findings

Question 8

Sub. Obj. Assessment, Plan format

Answer 8

SOAP problem oriented record

Question 9

Problem intervention evaluation model

Answer 9

PIE model is the focus is on nursing process.

Question 10

Data, action, response charting

Answer 10

DAR charting. focus charting on a specific problem

Question 11

Electronic documentation helps with?

Answer 11

Reduce medical errors
makes client medical history
increase accuracy of coding procedures

Question 12

A nurse is discussing problem oriented medical records with a group of new nurses. Which info should the nurse include?

Answer 12

A problem oriented medical record promotes information sharing among members of interdisciplinary team.

Question 13

who can access clients chart on the unit?

Answer 13

Admitting provider
charge nurse on the unit
the client

Question 14

Who started EHR?

Answer 14

The institute of Medicine