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PN 108 FINAL EXAM WITH {100} QUESTIONS AND VERIFIED ANSWERS $16.49   Add to cart

Exam (elaborations)

PN 108 FINAL EXAM WITH {100} QUESTIONS AND VERIFIED ANSWERS

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PN 108 FINAL EXAM WITH {100} QUESTIONS AND VERIFIED ANSWERS...

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  • October 30, 2024
  • 10
  • 2024/2025
  • Exam (elaborations)
  • Unknown
  • PN 108
  • PN 108
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intervention - ANSWER care provided to improve a situation

Charting, recording, documenting - ANSWER the Process of adding
information to a chart is called

Documentation - ANSWER is an integral part of the implementation
phase of the nursing process and is necessary for the evaluation of
patient care and for reimbursement for the cost of care provided

DRG - ANSWER diagnostic related group a group that classifies
patients by age, diagnosis, surgical procedure, and other information
with 25 major diagnostic categories and hundreds of different
subcategories

basics rules of documentation - ANSWER all documents should have
the correct patient name identification number, date of birth, date and
time if appropriate

Basic rules for documentation - ANSWER avoid use of general empty
phases such as status unchanged or had good day

basic rules for documentation 3 - ANSWER be objective in charting:
only what you hear, see, feel, smell

basic rules for documentation 4 - ANSWER Be timely, specific,
accurate, and complete

basic rules for documentation 5 - ANSWER Chart after Care is
provided, not before

basic rules for documentation 6 - ANSWER chart all ordered careas
given or explain the deviation, ex. NPO, nothing by mouth, for
laboratory, off unit, refused

, basic rules for documentation 7 - ANSWER chart as soon and as often
as necessary

basic rules for documentation 8 - ANSWER Chart facts avoid
judgmental terms and placing blame.

basic rules for documentation 9 - ANSWER Chart only your own care,
observations, and teaching, never chart for anyone else.

basic rules for documentation 10 - ANSWER Describe each item as
you see it

Basic rules for Documentation 11 - ANSWER Document only what you
observe not opinions, never use charging to accuse someone else

Basic rules for documentation 12 - ANSWER Fill all spaces leave no
empty lines chart consecutively go line by line do not Left margin.

Basic rules for documentation 13 - ANSWER Follow each institution's
policy and procedures for charting

Basic rules for documentation 14 - ANSWER Follow rules of grammar
and punctuation

Basic rules for documentation 15 - ANSWER If a charting error is
made, identify the error according to the facility's policy and make the
correct entry.

Basic rules for documentation 16 - ANSWER If you question and order
record that clarification was sought

Basic rules for documentation 17 - ANSWER Note patient response to
treatments and response to analgesics or other special medications

Basic rules for documentation 18 - ANSWER Sign each block of
charting or entry as directed by the agency policy

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