NSG 212 exam 2 | Questions & Answers (100 %Score) Latest Updated 2024/2025
Comprehensive Questions A+ Graded Answers | With Expert Solutions
discussion - informal oral consideration of a subject by 2 or more healthcare personnel
report - oral, written, or computer-based communication intended to convey info to others
record - also called chart or client record. formal, legal document that provides evidence of a client's
care. can be written or computer based
documentation - is anything written or printed that is relied on as a record or proof for authorized
persons. must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain
continuity of care, track client outcomes, and reflect current standards of nursing practice
ensuring confidentiality of computer records - personal password that is not to be shared. never leave a
computer terminal unattended after logging on. do not leave client info displayed on the monitor where
others may see it. shred all unneeded computer generated worksheets. use confidential trash cans.
know the facilities policy and procedure for correcting an entry error. follow agency procedures for
documenting sensitive material. IT must install a firewall to protect server from unauthorized access
usual policy for correcting an entry error - a narrative entry in the medical record stating that an error
was made. when correcting or making a change to an entry, the original entry should be viewable, the
current date and time should be entered, the person making the change should be identified, and the
reason for making the change should be noted
purposes of client records - communication, planning client care, auditing health care agencies,
research, education, reimbursement, legal documentation, health care analysis
communication - prevents fragmentation, repetition, and delays in care
labs drawn, patient bathed, medication ordered
planning client care - nurses use baseline and ongoing data to evaluate effectiveness of the care plan
wound care - documentation of status
, auditing health agencies - Review client records for quality assurance purposes
research - treatment plans for a number of clients with the same health problems can yield information
helpful in treating other clients
reimbursement - from the federal government, must contain correct DRGs, the DRG classification
system divides possible diagnoses into motor than 20 major body systems and subdivides them into
almost 500 groups for the purpose of medicare reimbursement
legal documentation - admissible in court in evidence unless client objects because information client
gives to primary care provider is confidential
health care analysis - identify agency needs such as over utilized and underutilized hospital services
in the court of law... - "care not documented is care not provided"
legal issues - individualized, goal-directed record needs to describe exactly what happened to client
4 common issues in malpractice caused by inadequate documentation are - not charting the correct
time when events occurred, failing to record verbal orders or failing to have them signed, charting
actions in advance to save time, documenting incorrect data
source-oriented record - traditional client record. each discipline makes notations in a separate section.
information abut a particular problem distributed throughout the record. narrative charting
different sheets/forms for different groups (RNs, MDs, PT, OT)
narrative charting (part of source oriented record slide) - written notes that include routine care, normal
findings, and client problems. often chronological
problem oriented medical record (POMR or POR) - data arranged according to patient problem, health
team contributes to the problem list, plan of care, and progress notes. encourages collaboration. easier
to track status of problems. vigilance required to maintain problems list. assessments and interventions
must be repeated when more than one problem exists
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