week 11 funda

Question 1

• Provides efficient and effective method of sharing information. It allows to convey meaningful
  data about the client.

Answer 1

Communication

Question 2

Provide data which the entire health team uses to plan care for the client.

Answer 2

Planning client care

Question 3

Monitors the quality of care received by the client and the
competence of health care givers.

Answer 3

Auditing health agencies

Question 4

– Provides valuable health related data for research.

Answer 4

• Research

Question 5

Serves as an educational tool for students in health discipline

Answer 5

Education

Question 6

Provides the basis for decisions regarding care to be provided and subsequent reimbursement
to the agency to cover health related expenses.

Answer 6

Reimbursement

Question 7

– It is admissible as evidence in a court of law.

Answer 7

Legal documentation

Question 8

Provides statistical information that can be utilized for planning people’s future needs

Answer 8

Health care analysis-

Question 9

This is the most familiar method of documenting nursing care. It is a diary or story format in chronological order. It is us
ed to document the patient’s status, events, treatments, interventions, and patient’s response to interventions.

Answer 9

Narrative Format

Question 10

This style originated from the medical model. Documentation is focused on the patient’s problems.
It reflects only certain aspects of the nursing process. It does not address the evaluation process of care.

Answer 10

Problem-Oriented Charting (SOAP)

Question 11

This is a modified version of SOAP. It adds Implementation (I), Evaluation (E), and Revision (R).
Revision or Reassessment refers to the changes that must be made in the initial or original plan.

Answer 11

SOAPIE or SOAPIER
This is a modified

Question 12

• a digital medical record that can be accessed, managed, & edited by multiple
  healthcare providers due to conformity to a standard

Answer 12

. EHR (Electronic Health Record)

Question 13

The purpose is to communicate specific information to a person or group of people

Answer 13

reporting

Question 14

Change-of-Shift Reports

Answer 14

. A report given to all nurses on the next shift. The purpose of which is to provide
continuity of care for clients by providing the new caregivers a quick summary of client’s needs and details of
care to be given.

Question 15

Incident report

Answer 15

is a form that filled up to record the details of accidents, patient injury and other unusual events
that occur in a health care facility such as a hospital or nursing home. It is also called an accident report which
documents the exact details of the accident or unusual event while the information is still fresh in the minds of
those who witness the event

Question 16

is a mechanism that enables a patient’s health needs to be comprehensively managed using
resources beyond those available at the location they access care from, be it in a community unit, dispensary,
health center or a higher-level health facility. h

Answer 16

referral system