week 4 documentation Flashcards
1
Q
what are nursing documentation standards set by
A
federal and state regulations
state statutes
standards of care
accreditation agencies
2
Q
legal guidelines for recording
A
correct all eros
do not record personal opinions just facts
no blank spaces
write legible
chart only for yourself
begin each entry with date/time and signature
keep password secure
3
Q
guidelines for quality documentation and reporting
A
factual accurate complete current organized
4
Q
mothods of recording process notes
A
SOAP
SOAPIE
PIE
focus charting
5
Q
what just SOAP stand for
A
subjective
objective
assessment
plan
6
Q
what does SOAPIE stand for
A
subjective objective assessment plan intervention evaluation
7
Q
what does PIE stand for
A
problem
intervention
evaulation
8
Q
what does focus charting mean
A
data
action
response
9
Q
- A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to
A. Exchange information among health care members.
B. Provide information about patients from one unit to another unit.
C. Ensure proper care for the patient.
D. Aid in the hospital’s quality improvement program.
A
D
