Exam (elaborations)
NURS 371 SELU Gibbs Exam With Complete Solutions Latest Update
- Course
- NURS 371
- Institution
- University Of Michigan
NURS 371 SELU Gibbs Exam With Complete Solutions Latest Update
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NURS 371 SELU Gibbs Exam 1 2024-2025 With Complete Solutions Latest
Update
documentation
record of pt status and care. can be written, electronic, or a combo
reporting
oral communication to maintain continuity of care, build team relationships, and
collaborate to improve patient care
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,documentation uses
- communication
- continuity of care
- quality improvement
- legal record
- planning/evaluating client outcomes
5 C's of documentation
Clear
Complete
Concise
Comprehensive
Correct
documenting, recording, and charting are
interchangeable
source-oriented record system
each discipline records their findings in separate sections of health record
advantages to source-oriented record systems
everything is nice, neat in its separate section
disadvantages to source-oriented record systems
info is fragmented
problem-oriented record systems
organized around the patient's problems. 4 parts: database, problem list, plan of
care, progress notes
advantages to problem-oriented record systems
makes monitoring progress easier
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, disadvantages to problem-oriented record systems
requires cooperative spirit among healthcare personnel
charting by exception (CBE)
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
reduces time spent on charting and increases time caring for pt
disadvantages of charting by exception
information is omitted which leads to med/pt errors
confidentiality breaches
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
enhances communication, improves data access, saves time, improves quality,
safe
disadvantages of EHR
expensive, downtime, change is difficult
Nursing Process
ADPIE: assessment, diagnosis, planning, implementation, evaluation
Clinical Judgement Model
RAPGTE: recognize cues, analyze cues, prioritize hypothesis, generate solutions,
take action, evaluate outcomes
PIE charting
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