Exam (elaborations)
Nurs 371 Exam Questions And Answers Latest Update
- Course
- NURS 371
- Institution
- University Of Michigan
Nurs 371 Exam Questions And Answers Latest Update
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Nurs 371 Exam 2024-2025 QuestionsAnd Answers Latest Update
Documentation is - The written or electronic legal record of all pertinent
interactions with the patient assessing diagnosing planning implementing and
evaluating
Characteristic of effective documentation - Consistent with professional and
agency standerds, complete , accurate, concise, factual, organized and timely,
legally prudent, confidential
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,What is confidential? - All information about patients written on paper spoken
aloud saved on commuter (Name, address, phone, fax social security, reason the
person is sick, assessments and treatments patient receives, information about
past health conditions)
A nurse who fails to log off a commuter after documenting patient care has
breached patient confidentiallity true or false - True
A patient has the right to obtain review and revise the patient information in his
or her health record True or false - False
Records included: - client identification and demogrphic data, informed consent
for treatment and procedures, admission nursing history, nursing diagnoses or
problems, nursing or multidiscriplinary care plan includes respiratory disease,
records of nursing care treatment and evaluation, medical history, medical
diagnosis, therapy orders, medical and health discipline progress notes, reports of
physical examinations, reports of diagnostic studies, summary of operative
procedures, discharge plan and summary
Purpose of patient records - Communication with other healthcare professionals,
records of diagnostic and therapeutic orders, care plannning, quality process and
performance improvement, research, decision analysis, education, credentialing
regulation and legislation, legal and historical documentation, reimbursement,
facilitate patient care, serve as a financial and legal record, help in clinical
research, support decision analysis
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,Guidelines for receiving verbal orders in an emergency - record the orders in
patients medical records, read back the order to verify accuracy, date and not the
time orders were issued in emergency, record VO, the name of the physician or
nurse practitioner followed by nurses name and title, the registered professional
nurse nurse must see that the orders are transcribed according to procedure
Terminology used: - Medical terminology used to facilitate communication,
breakdown medical terminology into the three parts prefix root suffix
Terminology Abbreviation notes - Keep to standard abbreviation different areas
or specialties vary, know approved abbreviation for specific agency
Documentation Essentials Legal document: What you need: - Black ink, contain
facts and be accurate, legible, brief/concise, exact time (may be military time),
logical by time and content, Errors/Omissions, no blank spaces, signature
Good assessors are usuallly good charters why? - Assessing from head to toe
paining a good picture should chart what you did and saw
Charting: - Takes time and practice, practice, proactive, you will always be
perfecting the skill
When to chart? - Admission, assuming care, transferring a patient, discharging a
patient
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, Types of entries: - Newly admitted patient, opening notes for shift, interval
notes(when something has changed), anything abnormal, any change, test, lab,
doctor visit, dietitian show orders carried out, transfer discharge
Documentation essentials: - Patient teaching, entries should be objective avoid
good, bad, seems like, do symptom analysis on complaints/pain, Entries must
reflect patient needs if you find something wrong you must chart what you did
and how your patient responded, dressing should not location attachments
drainage not skin condition if removed, tubes state type placement infusion site
condition drainage suction, Mar available for routine meds PRN are entered in
narrative notes with assessment intervention and response note meds not given
(when patient complains of pain state nurse notified , Psychosocial-LOC and
safety, ADL-flow sheet/transfer needs, Jewelry- describe (gold-yellow) where sent
and who recieved, spiritual care- not expression of grief/anger symbols/rituals,
sins of distress sources of hope, safety:side rails ambulation call light restraints
teaching about safety incident form is fall, elderly:ADL mobility safety mental
status affective behavior
Methods of documentation: source oriented - Separate division for each
discipline, may be narrative
Methods of documentation problem oriented - data base, problem list, plans,
progress
Documentation formats-problem oriented: - SOAP: subjective data, objective
data, assessment, plan
APIE: assessment, problems, interventions, evaluations
Focus:Data, action, response
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