Ch3 Documentation (1)

pdf

School

Upper Valley Educators Institute *

*We aren’t endorsed by this school

Course

1272

Subject

Chemistry

Date

Feb 20, 2024

Type

pdf

Pages

Uploaded by JudgeEnergy12732

Ch 3 Documentation Matching ____1. CBE ____2. DRGs ____3. EHR ____4. HIPAA ____5. MDS ____ 6. POC ____ 7. DARE ____ 8. SBARR ____ 9. PIE ____10. SOAPE a. Plan, intervention, evaluation b. Data, action, response, education c. Situation, background, assessment, recommendation, read back d. Charting by exception e. Subjective, objective, assessment, plan, evaluation f. Electronic health record g. Minimum data sets h. Point of care i. Diagnosis-related groups j. Health Insurance Portability and Accountability Act Open Book Quiz 1) Name the five basic purposes for written patient records. 2) What is a diagnosis-related group? 3) List the four common issues in malpractice caused by inadequate documentation. 4) Define narrative charting and describe what is included in its implementation. 5) What does the acronym SOAPIER describe? 6) How is the focus charting format used?

7) What are the procedures a nurse should follow when filling out an incident report? 8) Describe acuity charting and explain why it is used. 9) Who has ownership and access rights to health care records? 10) What are the major concerns regarding electronic documentation? NCLEX REVIEW QUESTIONS 1. What is considered an appraisal by a professional co-worker of the manner in which an individual nurse conducts practice, education, or research? a. Peer review b. Assessment c. Documentation d. Accountability 2. What form on the patient’s chart do nurses record their observations, care given, and the patient’s responses? a. Health care provider’s orders b. Health record c. DRGs Nurses’ d. notes 3. The nurse is organizing the tasks and care that are required throughout the work shift. What is the best time to plan on documenting patient care? a. During lunch b. As soon as possible after completion of care c. At the end of the shift d. Only when necessary 4. During which phase of the nursing process does documentation take place? a. Planning b. Evaluation c. Implementation d. Assessment 5. Considering the patient’s medical record is a legal document, what is the most important consideration the nurse should make? a. Document only what the patient says. b. Clearly indicate goal-directed nursing care. c. Write as little as possible so as not to incriminate yourself. d. Provide information on only the abnormal activities that occur.

6. As a newly hired nurse, what is the best way to chart using correct abbreviations? a. Ask the other nurses on the unit to verify the used abbreviations. b. Don’t worry about abbreviations; they are not that important. c. Chart using the abbreviations learned in school. d. Check to see if the facility has a published list of abbreviations. 7. When charting by exception, which acronym is generally used? a. SOAPE b. SOAPIER c. PIE d. DARE 8. A patient has been admitted to the medical floor. Whose responsibility is it to complete the patient’s initial admission nursing history, physical assessment, and development of the care plan? a. Social worker b. Health care provider c. LPN d. RN 9. Computer charting is becoming an increasingly common way to document. How often should the password be changed? a. Every 6 months b. Every 4 days c. With current technology, it is not necessary to change passwords d. At the discretion of the institution 10. The nurse is preparing to document patient care. What data is most important for the nurse to include? (Select all that apply.) a. Temperature of the environment b. Type of procedure performed c. Family members present d. Patient’s pain level e. Time of care Short Answer 1. The nurse does not have time to document a procedure after it was completed Discuss how the nurse would handle a “ late entry. ” 2. Compare and contrast focused charting, charting by exception, and narrative charting. 3. Briefly identify how long-term and home health care documentation are different from acute care (hospital) documentation.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version