Ch3 Documentation (1).pdf

docx

School

Upper Valley Educators Institute *

*We aren’t endorsed by this school

Course

1272

Subject

Chemistry

Date

Feb 20, 2024

Type

docx

Pages

Uploaded by JudgeEnergy12732

Ch 3 Documentation Matching __D__1. CBE __I__2. DRGs __F__3. EHR __J__4. HIPAA __G__5. MDS __H__ 6. POC __B__ 7. DARE __C__ 8. SBARR __A__ 9. PIE __E__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.  Documented communication, Permanent record for accountability, Legal record of care, Teaching, and Research and data collection. 2) What is a diagnosis-related group?  A System that classifies patients by age, diagnosis, and surgical categories; used to predict the use of hospital resources including the length of stay.

3) List the four common issues in malpractice caused by inadequate documentation.  Not charting the correct time that events occurred of that and event occurred at all, failing to record verbal orders, charting nursing care in advance, and documenting incorrect data. 4) Define narrative charting and describe what is included in its implementation.  Traditional system of charting in which the nurse documents in story form all pertinent patients, observations, care and responses in the nurse notes section of patients records. 5) What does the acronym SOAPIER describe?  Format used in POMR. Components include Subjective data (S) reported by the patient, Objective data (O) acquired by inspection, percussion, auscultation, and palpitations, and by test, usually measurable findings; Assessment (A) of the problem; Plan (P) of care; Intervention (I); Evaluation (E) of the patient’s response to the treatment plan; Revisions (R) changes made. 6) How is the focus charting format used?  It is used by using the nursing process and more positive concept of the patient’s needs rather than medical diagnoses and problems. (DARE) Data, Action, Response and evaluation, Education. 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.  It rates the patient’s severity of illness and determines efficient staffing patterns. 9) Who has ownership and access rights to health care records?  The original health record or chart is the property of the institution or health care provider. 10) What are the major concerns regarding electronic documentation?  Confidentiality, access to information and inappropriate altercations in patient records are areas of concern. 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

Your preview ends here

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

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

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.”  When the nurses has time the can go back to the patients chart and add the entry with (LE) late entry document what needs to be stated and make sure she put an arrow where the entry should be. 2. Compare and contrast focused charting, charting by exception, and narrative charting.  Focused charting was developed by nurses using the nursing process and use the DARE format. Charting by exception has the nurses doing all the initial assessments in the beginning of the shift and only adding additional treatment throughout the day. Narrative Charting is from computerized and noncomputerized charting which the nurses record their observations, care given, and patient response. 3. Briefly identify how long-term and home health care documentation are different from acute care (hospital) documentation.  The nature of the home health setting dictates that a narrower scope of people witness the majority of care, and in long term care the patient live in the facility. And are referred to as residents.