©SOPHIABENNETT@2024-2025 Monday, August 19, 2024 12:35 AM
Adult Nursing 1 Exam 1 Study guide
with complete solutions
What information is confidential in a healthcare setting? - Answer✔️✔️-All
information about patients regardless of if it is handwritten, saved on a
computer, or spoken out loud.
Give a few examples of breaches of confidentiality - Answer✔️✔️--
Discussing patient information where it can be overheard
-Leaving patient medical information in a public area
-Leaving patient information up on a computer that is unattended
-Sharing or exposing passwords
-Improperly accessing, releasing or reviewing a patient's record out of
curiosity or concern
-Improperly accessing, releasing, or reviewing any patient information
regardless of your relationship with the patient
Information/Documentation should be clear, complete, concise, accurate,
and factual. What are other important aspects of Documentation? -
Answer✔️✔️--Documentation should reflect the nursing process and your
professional responsibilities
-Avoid generalizations in documentation
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,©SOPHIABENNETT@2024-2025 Monday, August 19, 2024 12:35 AM
-Note problems/situations in chronological order, add/update and delete
problems as needed
-Record precautions or preventative measures used
-Avoid stereotypes
-Document the nursing response to questionable orders or treatment
PIE Charting - Answer✔️✔️-method of recording the client's progress under
the headings of problem, intervention, and evaluation
Focus charting - Answer✔️✔️-Brings the focus of care back to the patient and
the patient's concerns. Narrative portion uses DAR (Data, Action,
Response) format
Charting by exception - Answer✔️✔️-only documenting abnormal
findings/issues
-everything is normal except for...
SOAP format - Answer✔️✔️-method of charting narrative progress notes;
organizes data according to subjective information (S), objective
information (O), assessment (A), and plan (P)
Narrative notes - Answer✔️✔️-address routine care, normal findings, and
patient problems identified in the plan of care
ISBAR - Answer✔️✔️-Introduction
Situation
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, ©SOPHIABENNETT@2024-2025 Monday, August 19, 2024 12:35 AM
Background
Assessment
Recommendation
SOAPIE - Answer✔️✔️-subjective
objective
assessment
plan
intervention
evaluation
Change of shift report - Answer✔️✔️-Includes:
-Basic information about each patient (name, room, bed, diagnosis,
consulting physicians)
-Current appraisal of each patient's health status
-Current orders
-Abnormal occurrences during shift
-Any unfilled orders that need to be continued onto next shift
-Patient's questions, concerns, needs
-Reports on transfers/discharge
Page 3 of 23
Adult Nursing 1 Exam 1 Study guide
with complete solutions
What information is confidential in a healthcare setting? - Answer✔️✔️-All
information about patients regardless of if it is handwritten, saved on a
computer, or spoken out loud.
Give a few examples of breaches of confidentiality - Answer✔️✔️--
Discussing patient information where it can be overheard
-Leaving patient medical information in a public area
-Leaving patient information up on a computer that is unattended
-Sharing or exposing passwords
-Improperly accessing, releasing or reviewing a patient's record out of
curiosity or concern
-Improperly accessing, releasing, or reviewing any patient information
regardless of your relationship with the patient
Information/Documentation should be clear, complete, concise, accurate,
and factual. What are other important aspects of Documentation? -
Answer✔️✔️--Documentation should reflect the nursing process and your
professional responsibilities
-Avoid generalizations in documentation
Page 1 of 23
,©SOPHIABENNETT@2024-2025 Monday, August 19, 2024 12:35 AM
-Note problems/situations in chronological order, add/update and delete
problems as needed
-Record precautions or preventative measures used
-Avoid stereotypes
-Document the nursing response to questionable orders or treatment
PIE Charting - Answer✔️✔️-method of recording the client's progress under
the headings of problem, intervention, and evaluation
Focus charting - Answer✔️✔️-Brings the focus of care back to the patient and
the patient's concerns. Narrative portion uses DAR (Data, Action,
Response) format
Charting by exception - Answer✔️✔️-only documenting abnormal
findings/issues
-everything is normal except for...
SOAP format - Answer✔️✔️-method of charting narrative progress notes;
organizes data according to subjective information (S), objective
information (O), assessment (A), and plan (P)
Narrative notes - Answer✔️✔️-address routine care, normal findings, and
patient problems identified in the plan of care
ISBAR - Answer✔️✔️-Introduction
Situation
Page 2 of 23
, ©SOPHIABENNETT@2024-2025 Monday, August 19, 2024 12:35 AM
Background
Assessment
Recommendation
SOAPIE - Answer✔️✔️-subjective
objective
assessment
plan
intervention
evaluation
Change of shift report - Answer✔️✔️-Includes:
-Basic information about each patient (name, room, bed, diagnosis,
consulting physicians)
-Current appraisal of each patient's health status
-Current orders
-Abnormal occurrences during shift
-Any unfilled orders that need to be continued onto next shift
-Patient's questions, concerns, needs
-Reports on transfers/discharge
Page 3 of 23
