Ch 16, 19 questions with 100% correct answers 2024

Ch 16, 19 Identify the purposes of the client record - Communication among health professionals, Education of health professionals, Legal documentation detailing the client's care, Quality assurance, Identification of the cost of care, Health research What are the key differences between source-oriented and problem-oriented records? - The source-oriented record is organized according to discipline. Each discipline charts in its defined section of the chart. The problem-oriented record is organized around a patient problem list. All disciplines chart on shared notes that are referenced to the identified problem. Summarize the characteristics of narrative - tells the story of the patient's experience in a chronological format. Patient status, activities, and response to treatment may all be included in narrative charting. Summarize the characteristics of SOAP - is organized according to subjective data, objective data, assessment, and plan. This format may be used to address single problems or to write summative patient notes. Summarize the characteristics of PIE - is organized according to problem, interventions, and evaluation. Problems are identified at the admission assessment. Subsequent entries begin with identification of the problem number. This type of charting establishes an ongoing care plan. Summarize the characteristics of Focus® - is not necessarily organized according to problems. It can highlight the client's concerns, problems, or strengths. Charting occurs in three columns. The first column contains the time and date. The second column identifies the focus or problem addressed in the note. The third column contains charting in a DAR format. DAR is an acronym for data, action, and response. Summarize the characteristics of CBE - utilizes pre-printed flowsheets to document most aspects of care. CBE assumes that unless a separate entry is made—an exception—all standards have been met with a normal response. CBE flowsheets vary by specialty and in some cases even by diagnosis. Charting by exception simplifies nursing documentation by eliminating the need to document routine, stable patient information. It should be used in conjunction with flowsheets and brief narrative charting to ensure comprehensive documentation. This form of documentation does not minimize risks because nurses need to be sure they have included both routine and variant findings. It can be used successfully in any