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NURS1000 - Documentation Exam Latest Update
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NURS1000 - DocumentationExam Latest Update
Standards of practice for nursing documentation - Answer must be accurate,
comprehensive, and flexible enough for members of the health care team to retrieve
critical data, maintain continuity of care and track patient outcomes, and it must reflect
current standards of nursing practice.
confidentiality of nursing documentation - Answer a nurse is legally and ethically
obligated to keep information about patients confidential
PIPEDA - Answer Personal Information Protection and Electronic Documents Act
A federal legislation protecting personal information, including health information.
Professional misconduct - Answer failing to keep records as required
falsifying a record
signing or issuing a document that the member knows includes a false statement
giving information about a client without consent
Charting by exception - Answer charting deviations from established norms or abnormal
findings
case management plan - Answer incorporates a multidisciplinary approach to
documenting patient care
critical pathways or care maps - Answer multidisciplinary care plans that include
patient health concerns, key interventions, and expected outcomes within an
established time frame
source records - Answer the patients chart is organized so that each discipline has a
separate section in which to record data
narrative documentation - Answer the use of story-like format to document information
specific to patient conditions and nursing care
problem orientated medical records - Answer a method of documentation that
emphasizes the patients problems
Data are organized by problem or diagnosis
SOAP - Answer Subjective data
, Objective data
Assessment
Plan
SOAPIE - Answer Subjective data
Objective data
Assessment
Plan
Intervention
Evaluation
Problem oriented charting - PIE - Answer Problem (objective)
Interaction
Evaluation
Focus Charting - DAR - Answer Data (subjective & objective)
Action
Response
SBAR - Answer Situation
Background
Assessment
Recommendation
ISBARR - Answer Identification
Situation
Background
Assessment
Recommendation
Read back
A manager is reviewing the nurses' notes in a patient's medical record. She finds the
following entry: "Patient is difficult to care for, refuses suggestion for improving
appetite." Which of the following directions should the manager give to the staff nurse
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