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NUR 380 FUNDAMENTALS EXAM 2 questions and answers graded A+ 2024/2025
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NUR 380 FUNDAMENTALS EXAM 2 questions and answers graded A+ 2024/2025
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NUR 380 FUNDAMENTALS EXAM 2What organization mandates computer databases to expedite accredidation procedure?
The Joint Commission
PURPOSES for MEDICAL RECORDS
a) communication
b) prison documentation
c) economic billing
d) training
e) research
f) auditing/monitoring
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Purpose of reporting
provide continuity of care and decorate verbal exchange amongst all group participants who
offer care to the identical clients, hence promoting purchaser protection
Elements of Documentation (4)
-Factual
-Accurate & Concise
-Complete & Current
-Organized
documentation codecs
, a) Flow Charts - document and show trends in important symptoms, blood glucose degrees,
ache stage and different frequently performed tests
b) Narrative Documentation - information information as a sequence of activities
c) Charting by using exception (CBE) - standardized forms that pick out normal findings/values
and lets in selective documentation of bizarre findings.
D) Problem oriented medical information (POMR) - consists of database, hassle list, care plan,
and progress notes.( ex. SOAP, PIE, DAR)
S.O.A.P
subjective, objective, evaluation, plan
P.I.E.
Hassle, intervention, assessment
D.A.R.
Records, action, reaction
Reporting Formats
change-of-shift reviews,
cellphone reviews,
cellphone or verbal prescriptions,
switch reviews,
incident reviews.
Health Informatics
Application of pc and statistics science in all basic and carried out biomedical sciences to
facilitate the acquisition, processing, interpretation, most suitable use, and verbal exchange of
health-related records.
Nursing informatics
the technology of using laptop statistics structures inside the exercise of nursing.
T.I.G.E.R.
Technology Informatics Guiding Education Reform
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