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NURS 371 SELU Gibbs Exam 1 questions with correct answers
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NURS 371 SELU Gibbs Exam 1 questions with correct answers
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NURS 371 SELU Gibbs Exam 1 questions with correctanswers
documentation Correct Answer-record of pt status and care. can be
written, electronic, or a combo
reporting Correct Answer-oral communication to maintain continuity of
care, build team relationships, and collaborate to improve patient care
documentation uses Correct Answer-- communication
- continuity of care
- quality improvement
- legal record
- planning/evaluating client outcomes
5 C's of documentation Correct Answer-Clear
Complete
Concise
Comprehensive
Correct
documenting, recording, and charting are Correct Answer-
interchangeable
,source-oriented record system Correct Answer-each discipline records
their findings in separate sections of health record
advantages to source-oriented record systems Correct Answer-
everything is nice, neat in its separate section
disadvantages to source-oriented record systems Correct Answer-info is
fragmented
problem-oriented record systems Correct Answer-organized around the
patient's problems. 4 parts: database, problem list, plan of care, progress
notes
advantages to problem-oriented record systems Correct Answer-makes
monitoring progress easier
disadvantages to problem-oriented record systems Correct Answer-
requires cooperative spirit among healthcare personnel
charting by exception (CBE) Correct Answer-only significant findings
are documented. assumes all standards have been met and pt responded
normally unless a separate entry has been made
advantages of charting by exception Correct Answer-reduces time spent
on charting and increases time caring for pt
, disadvantages of charting by exception Correct Answer-information is
omitted which leads to med/pt errors
confidentiality breaches Correct Answer-leaving info in public.
discussing pt in public. staying logged in to computer. sharing
passwords. improperly accessing info not r/t your assignment
advantages of EHR Correct Answer-enhances communication, improves
data access, saves time, improves quality, safe
disadvantages of EHR Correct Answer-expensive, downtime, change is
difficult
Nursing Process Correct Answer-ADPIE: assessment, diagnosis,
planning, implementation, evaluation
Clinical Judgement Model Correct Answer-RAPGTE: recognize cues,
analyze cues, prioritize hypothesis, generate solutions, take action,
evaluate outcomes
PIE charting Correct Answer-problem, intervention, evaluation
SOAP charting Correct Answer-subjective, objective, assessment, plan
narrative note Correct Answer-provides info on details of client care.
tracks client's changing health status and their progress towards goals
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