Adult Nursing 1 Exam 1 Study guide with complete solutions
0 view 0 purchase
Course
Adult Nursing
Institution
Adult Nursing
Adult Nursing 1 Exam 1 Study guide
with complete solutions
What information is confidential in a healthcare setting? - Answer️️ -All
information about patients regardless of if it is handwritten, saved on a
computer, or spoken out loud.
Give a few examples of breaches of confidentiality - ...
Adult Nursing 1 Exam 1 Study guide
with complete solutions
What information is confidential in a healthcare setting? - Answer✔️✔️-All
information about patients regardless of if it is handwritten, saved on a
computer, or spoken out loud.
Give a few examples of breaches of confidentiality - Answer✔️✔️--
Discussing patient information where it can be overheard
-Leaving patient medical information in a public area
-Leaving patient information up on a computer that is unattended
-Sharing or exposing passwords
-Improperly accessing, releasing or reviewing a patient's record out of
curiosity or concern
-Improperly accessing, releasing, or reviewing any patient information
regardless of your relationship with the patient
Information/Documentation should be clear, complete, concise, accurate,
and factual. What are other important aspects of Documentation? -
Answer✔️✔️--Documentation should reflect the nursing process and your
professional responsibilities
-Note problems/situations in chronological order, add/update and delete
problems as needed
-Record precautions or preventative measures used
-Avoid stereotypes
-Document the nursing response to questionable orders or treatment
PIE Charting - Answer✔️✔️-method of recording the client's progress under
the headings of problem, intervention, and evaluation
Focus charting - Answer✔️✔️-Brings the focus of care back to the patient and
the patient's concerns. Narrative portion uses DAR (Data, Action,
Response) format
Charting by exception - Answer✔️✔️-only documenting abnormal
findings/issues
-everything is normal except for...
SOAP format - Answer✔️✔️-method of charting narrative progress notes;
organizes data according to subjective information (S), objective
information (O), assessment (A), and plan (P)
Narrative notes - Answer✔️✔️-address routine care, normal findings, and
patient problems identified in the plan of care
-Basic information about each patient (name, room, bed, diagnosis,
consulting physicians)
-Current appraisal of each patient's health status
-Current orders
-Abnormal occurrences during shift
-Any unfilled orders that need to be continued onto next shift
-Patient's questions, concerns, needs
-Reports on transfers/discharge
Page 3 of 23
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller SophiaBennett. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $10.49. You're not tied to anything after your purchase.
