NSC 114 Exam 2 Questions with Complete Solutions
Ethical and legal considerations - Answer-- Confidentiality of all patient information
- Client's record protected legally as a private record of client's care
- HIPAA regulations
- Responsibility in using records for the purpose of education ...
NSC 114 Exam 2 Questions
with Complete Solutions
Ethical and legal considerations - Answer-- Confidentiality of all patient information
- Client's record protected legally as a private record of client's care
- HIPAA regulations
- Responsibility in using records for the purpose of education and research
- dont chart for another nurse
- do not leave computer unattended
- only look at your pts charts
Purposes of Client Records - Answer-*communication - prevents delay in care
*planning client care - nurses use baseline and ongoing data to evaluate effectiveness
of the care plan
* auditing health agencies - review client records for quality assurance purposes
SAPT planning and goal setting - Answer-S- subject (always client)
A - action verb (will have)
P - performance criteria (no pain)
T - target time (by end of shift)
What not to document - Answer-* opinions
* assumptions
* for other health care professionals
* not about you its about PT
* judgemental terms
*dont make accusations
* dont state an error was made
documentation rules for paper - Answer-* do not leave a blank line above signature
* for late entries label with the time the note was written and begin with the words late
entry, and document the time the even occurred
* draw line and put error for wrong charting and initial corrections
Assertive nurse - Answer-maintain eye contact
speak firmly and clearly
project a clear tone of voice
focus on issues
maintains professional composer
speaks genially without sarcasm
,techniques to enhance communication among teams - Answer-SBAR
Call Out (method to communicate important info during a critical event)
Check Back (closes communication loop, verifies and validates information exchanged
reduces communication appointments)
Hand Off (method of sharing information when team members change)
factors affecting learning - Answer-- Age and developmental stage
- Motivation - Readiness - Active involvement
- Relevance - Feedback - Nonjudgmental support
- Simple to complex learning - Repetition - Timing
- Environment - Emotions - Physiological events
- Cultural aspects - Psychomotor ability
source-oriented record - Answer-paper format in which each health care group keeps
data on its own separate form
Narritive Charting - Answer-traditional part of the source-oriented record.
consist of written notes that include routine care, normal findings, and client problems.
POMR - Answer-Problem
Oriented
Medical
Records
***Divides records into four sections ***
**Data base (consist of all information known about the client)
**Problem list (is derived from the database. it is usually kept at the front of the chart
and serves as an index to the numbered entries in the progress notes)
** Plan of care (the initial list of orders or plan of care is made with reference to the
active problems)
* *Progress notes (chart entry made by all health professionals involved in a client's
care)
Progress notes form of charting in POMR - Answer-SOAP
S - Subjective data (consist of information obtained from what the client says)
O - Objective data (consist of information that is measured or observed by use of the
senses ex. vital signs)
A - Assessment (interpretation or conclusions drawn about the subjective and objective
data)
P - Plan (the plan of care designed to resolve the stated problem)
PIE charting - Answer-method of recording the client's progress under the headings of
problem, intervention, and evaluation
P - problem
I - intervention
E - evaluation
, Focused Charting (DAR) - Answer-data, action, response
occurs a lot in ER
progress notes
Charting by exception (CBE) - Answer-Documentation system in which only abnormal
or significant findings are recorded
1. Flow sheets - (example of flow sheets include graphic records of vital sign sheet, a
head and face assessment in a daily nursing assessment record)
2. standards of nursing care
3. bedside access to chart forms
Kardexes - Answer-Series of cards kept in a portable index file or on computer-
generated form that makes information quickly accessible
widely used, concise method of organizing and recording data about a client, making
information quickly accessible to all health professionals.
intake and output record - Answer-all routes of fluid intake and all routes of fluid loss or
output are measured and recorded on this form
I&O
MAR - Answer-include medication order, expiration date, medication name, and dose,
frequency of administrate and route, and nurses signature. allergies
M - medication
A - administration
R - record
skin assessment record - Answer-EHR - specifically utilizes braden assessment
include categories related to stage of injury, drainage, odor, culture information, and
treatments.
Nursing Discharge/Referral Summaries - Answer-completed when the client is being
discharged and transferred to another institution or home setting.
* * description of client's mental, physical, and emotional status at discharge or transfer
* * resolved health problems
* * unresolved continuing health problems
* * treatments that are to be continued
* * current meds
* * restrictions
* * functional self care abilities in terms of vision, hearing, speech mobility
* * comfort level
* * support people
* * client education
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