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Fundamentals Exam 5 Ch 18, 19, 35, 41, 44, 45 (1)
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Fundamentals Exam 5 Ch 18, 19, 35, 41, 44, 45 (1)
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Fundamentals Exam 5 Ch 18, 19, 35, 41, 44, 45What is documentation? - CORRECT ANSWER-The act of recording client assessments and care
in written or electronic form
A+
- creating a record of client assessments and care, and record data of what care was provided or
not provided
What is the purpose of the written record? - CORRECT ANSWER-- Communication between
providers
- Educational tool
- Legal documentation of care
- Quality improvement/research
- Reimbursement
What is standardized language? - CORRECT ANSWER-- standardized nursing terminology helps
to make nursing care and its effects on patients more visible
- NANDA, NIC, NOC
What is a source-oriented system of documentation? - CORRECT ANSWER-- very fragmented,
everybody is doing their own thing
- disciplines document in separate sections of the chart and it has scattered data
What is the problem oriented system of documentation? - CORRECT ANSWER-- organized
around client problems
- has 4 components: database, problem list, plan of care, and progress notes
,- promotes greater collaboration
What is narrative charting? - CORRECT ANSWER-- sequentially telling the story of that patient for
that shift
A+
- can be lengthy and disorganized
What is PIE charting? - CORRECT ANSWER-problem, intervention, evaluation
- used only in problem oriented charting, establishes an ongoing plan of care, can be used on daily
assessments and progress notes
What is SOAP charting - CORRECT ANSWER-SOAP = subjective, objective data, assessment,
planning
(most used by providers)
What is IER? - CORRECT ANSWER-Intervention
Evaluation
Revision
What is focus charting? - CORRECT ANSWER-Highlights the client's concerns, problems, or
strengths in three columns:
Column 1: Time and date
Column 2: Focus or problem being addressed
Column 3: Charting in a DAR format: Data, Action, Response
, What is charting by exception? - CORRECT ANSWER-- charting only significant findings or
exceptions to norms (saves time)
A+
What is FACT Documentation? - CORRECT ANSWER-Flow sheets individualize specific services
Assessment with baseline data
Concise progress notes
Timely entries
What is the nursing admission assessment? - CORRECT ANSWER-- record of baseline data from
which to monitor change
- helps forecast future needs (points out abnormal findings)
What is in the admission database? - CORRECT ANSWER-- chief complaint or reason for
admission
- physical assessment data
- vital signs, allergy information, current medications, ADLS status
- data about client support system and contact information
What are flow sheets? - CORRECT ANSWER-Documents on which frequent observations or
specific measurements are recorded (vital signs, wound care, intake and output)
What is a MAR? - CORRECT ANSWER--Comprehensive list of all ordered medications
-Medication allergies
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