*Pro. Nursing DOCUMENTATION Flashcards

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1
Q

ABD

A

abdomen

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2
Q

CBC

A

Complete Blood Count

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3
Q

C&S

A

Culture and Sensitivity

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4
Q

EHR

A

Electronic Health Record

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5
Q

CPOE

A

Computerized Provider Order Entry

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6
Q

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

A

Facilities can establish their own rules for documentation

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7
Q

Charting by exception

A

only chart unexpected findings

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8
Q

Sub. Obj. Assessment, Plan format

A

SOAP problem oriented record

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9
Q

Problem intervention evaluation model

A

PIE model is the focus is on nursing process.

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10
Q

Data, action, response charting

A

DAR charting. focus charting on a specific problem

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11
Q

Electronic documentation helps with?

A

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

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12
Q

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

A

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

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13
Q

who can access clients chart on the unit?

A

Admitting provider
charge nurse on the unit
the client

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14
Q

Who started EHR?

A

The institute of Medicine

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