NUR 342 Exam 2 Review Questions and Correct Answers
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Course
NUR 342
Institution
NUR 342
Purposes of PT record communication care planning quality improvement research education regulation reimbursement legal and historical documentation
Characteristics of effective documentation consistent with professional and agency standards complete accurate concise factual organized and timely l...
NUR 342 Exam 2 Review Questions and
Correct Answers
Purposes of PT record ✅communication
care planning
quality improvement
research
education
regulation
reimbursement
legal and historical documentation
Characteristics of effective documentation ✅consistent with professional and agency
standards
complete
accurate
concise
factual
organized and timely
legally prudent
confidential
Elements of documentation ✅content
timing
format
accountability
confidentiality
What is confidential ✅ALL PATIENT INFORMATION
Potential breaches in patient confidentiality ✅displaying info on public screen
sending info through email
discarding pt info in trashcans
overheard conversations
faxing confidential info to unauthorized persons
sending confidential messages overheard on pagers
Patient have the rights to: ✅see and copy their health record
update health record
get a list of disclosures
request a restriction on certain uses or disclosures
choose how to receive health info
,Duties of RN receiving verbal orders ✅record the orders in pts medical record
read back order to verify
date and note the time orders were issued
record orders, full name and title of physician
sign orders with name and title
Purpose of recording data ✅facilitate patient care
serve as a financial and legal record
help in research
support decision analysis
Standalone personal health records ✅patients fill in information from their own records;
the information is stored on patients computers or the internet
Tethered/connected personal health records ✅linked to a specific health care
organizations electronic health record (EHR) system or to a health plans information
system
methods of documentation ✅problem-oriented medical records (SOAPIE)
focus charting (DARP)
charting by exception
computerized documentation /EHR
PIE documentation ✅P - problem or nursing diagnosis for pt
I- interventions or actions taken
E-evaluation of the outcomes of interventions
Focus charting (DARP) ✅Data
Action
Response
Plan
(does not include quality of care and leaves room for malpractice accusations)
Problem - oriented medical records ✅defined database
problem list
care plans
progress notes
SOAPIE acronym ✅S- subjective data
O- objective data
A- assessment
P - plan
I - intervention
E- evaluation
Format for POMR
, Hand- off communication (ISBARR) ✅I - identify/introduction
S- situation
B- background
A- assessment
R - recommendation
R- read back of orders
Hand - off reports should include: ✅basic identifying info about pt
pt health status
current orders
abnormal occurrences during your shift
any unfilled orders that need to be continued onto next shift
family concerns/needs
reports on transfers/discharge
Types on intake to record on I/O records ✅liquids by mouth
flushes
IV fluids
meds (IV)
feedings
types of output to record ✅urine
gastric suction
diarrhea
drainage
vomiting
Types of flow sheets ✅graphic record
24-hour fluid balance record
medication record
24- hour patient care records
tasks that can be delegated to UAP ✅measure and record input/output
report changes in patients condition such as alteration in intake or changes in color,
amount, or odor of output
Nursing tasks that CANNOT be delegated ✅assessing I&O totals
comparing 24 hour totals over several days
monitoring and recording IV therapy, wound/chest tube drainage, tube feedings
Medication Legislation and standards ✅federal regulations (FDA)
state and local regulation
health care institution laws
Nurse Practice Acts regulation of nursing practice
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