Exam (elaborations)
FUNDAMENTALS OF NURSING- CHAPTER 18- DOCUMENTING AND REPORTING QUESTIONS WITH CORRECT ANSWERS 2024/2025
FUNDAMENTALS OF NURSING- CHAPTER 18- DOCUMENTING AND REPORTING QUESTIONS WITH CORRECT ANSWERS
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FUNDAMENTALS OF NURSING:
CHAPTER 18: DOCUMENTING AND
REPORTING QUESTIONS WITH
CORRECT ANSWERS 2024/2025
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BtwoBforms
reportingB-BcorrectBanswer-oralBcommunicationBaboutBaBpatient'sBstatus
medicalBrecordBorBchartB-BcorrectBanswer-
historically,BtheBcollectionBofBdocumentation,Borders,BandBotherBcareBinfoBforBaBptaient
healthBrecordB-BcorrectBanswer-
moreBcommonlyBreferredBtoBcomparedBtoBmedicalBrecord.BpermanentBfileBcontainingBallBrecordsBofBMedic
alBCareBreceived.
healthBrecordsBpermanentlyBdocuments:B-BcorrectBanswer-
1.Bcare,BinBchronologicalBorder,BprovidedBbyBallBhealthcareBproviders
2.BtheBpatient'sBresponsesBtoBinterventionsBandBtreatments
3.BimportantBfactsBaboutBaBclient'sBhealthBhistory,BincludingBpastBandBpresentBillnesses,Bexaminations,Btest
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PurposeBofBtheBwrittenBrecordB-BcorrectBanswer-1.BcommunicationBbetweenBproviders
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4.BqualityBimprovement
5.BresearchB
6.Breimbursement
7.Beducation
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CommunicationBpromotesBcontinuityBofBcare.
asBaBnurseByouBare:B-BcorrectBanswer-theBeyesBandBearsBofBtheBprovider
educationalBtoolB-BcorrectBanswer-
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Bdiag,Borders,BandBtreatmentsBbeforeBdirectBcareBbegins
legalBdocumentationBofBcareB-BcorrectBanswer-
theBhealthBrecordBwillBbeBscrutinizedBbyBlegalBexpersBifBaBdisputeBaboutBaBclient'sBcareBarises
qualityBimprovementB-BcorrectBanswer-
resultsBareBusedBtoBformulateBstrategiesBtoBimproveBcare,BdecreaseBlengthBofBstay,BcontrolBcosts,BandBpinp
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dBin-serviceBeducation
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partyBpayers,BbudgetBmanagers,BandBorganizationBbillingBstaffBuseBclientBhealthBrecordsBtoBdetermineBtheB
costBofBcare
StandardizedBnursingBterminologyB-BcorrectBanswer-
helpsBtoBmakeBnursingBcareBandBitsBeffectsBonBpatientsBmoreBvisible.BallowBresearchersBtoBretrieveBnursingB
dataBforBaggregationBandBanalysis
NANDABinternationalB-BcorrectBanswer-
nursingBlanguageBmodelsBareBusedBinBnursingBdocumentationBsuchBasBNANDA-I
, NICBstandsBforB-BcorrectBanswer-nursingBinterventionsBclassifications,BanotherBlanguageBmodel
NOCBstandsBforB-BcorrectBanswer-nursingBoutcomesBclassifications
NANDA-I,BNIC,BandBNOCB-BcorrectBanswer-TheBANABrecommendedBdocumentationBsystemsBuseBANA-
reccogniedBterminology
SourceBorientedBsystem:B-BcorrectBanswer-1.BdisciplinesBdocumentBinBseparateBsectionsBofBtheBchart
2.BcontainsBaBvarietyBofBsectionsBi.e.Badmission,BH&P,Bdiag,Bgraphic,Bnurses'Bnotes,BprogressBnotes,Blab,Breh
ab,BDCBplan,Betc
3.BdataBscattered,BmayBleadBtoBfragmentation
advantageBofBsourceBorientedBsystemB-BcorrectBanswer-
youBcanBeasilyBfindBtheBcareBprovidedBbyBeachBdiscipline
disadvantageBofBsourceBorientedBsystemB-BcorrectBanswer-
1.BdataBmayBbeBfragmentedBandBscatteredBthroughoutBtheBpatient'sBrecord
2.ByouBneedBtoBreviewBallBsectionsBofBtheBchartBtoBfullyBunderstandBtheBclient'sBconditionBandBcare
3.BitBisBdifficultBtoBtrackBtheBtreatmentsBandBclientBoutcomesBassociatedBwithBaBparticularBproblem
problemBorientedBsystemB-BcorrectBanswer-1.BorganizedBaroundBclientBproblems
2.BfourBcomponents:Bdatabase,BproblemBlist,BplanBofBcare,BandBprogressBnotes
3.BpromotesBgreaterBcollaboration
PORBadvantagesB-BcorrectBanswer-
1.BthereBisBaBcommonBproblemBlistBthatBincludesBinputBfromBallBdisciplines
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