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Nurs 122 Lecture Week One Questions And Answers Latest Updated
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Nurs 122 Lecture Week One Questions And Answers Latest Updated
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Nurs 122 Lecture Week One QuestionsAnd Answers Latest Updated
Discussion ANS✔✔ an informal oral consideration of a subject by two or more healthcare personnel to
identify a problem or establish strategies
report ANS✔✔ oral, written, or computer-based communication intended to convey information to
others
The process of making an entry on a patient record is called ANS✔✔ recording, charting, or
documenting
clinical record ANS✔✔ a formal, legal document that provides evidence of a patient's care
"The nurse has a duty to maintain confidentiality of all patient information" is said by who? ANS✔✔ The
American Nurses Association (ANA) Code of Ethics
PHI is the abbreviation for ANS✔✔ Protected Health Information
purposes of patient records include ANS✔✔ communication, planning patient care, auditing health
agencies, research, education, reimbursement, legal documentation, healthcare analysis
the traditional patient record is called ANS✔✔ a source-oriented record
narrative charting consists of what? ANS✔✔ Written notes which include routine care, normal findings,
and patient problems
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, examples of diagnostic reports are ANS✔✔ laboratory reports, x-ray reports, CT scan reports
examples of consultation reports are ANS✔✔ physical therapy and respiratory therapy
the abbreviation for POMR is ANS✔✔ problem-oriented medical record
what is a POMR? ANS✔✔ data is arranged according to the problems the patient has rather than
according to the source of the information
what are some advantages and disadvantages of a POMR? ANS✔✔ advantages: they encourage
collaboration, and that the problem list in the front of the chart alerts caregivers to the patient's needs,
making it easier to track the status of each problem
disadvantages: not all caregivers can use the charting format effectively, constant vigilance is required to
maintain an up-to-date problem list which can be inefficient
what is a database? ANS✔✔ all information known about the patient
SOAP is an acronym for ANS✔✔ subjective, objective, assessment, and planning
subjective data ANS✔✔ what the person says about himself or herself during history taking
objective data ANS✔✔ information that is seen, heard, felt, or smelled by an observer; signs
assessment ANS✔✔ interpretation or conclusions drawn about the subjective and objective data
interventions ANS✔✔ actions taken to correct or manage a patient's problems
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