Change of Shift Report communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped
Charting by Exception shorthand method for doc...
Nur 342 Exam Two Questions and
Correct Answers
Change of Shift Report ✅communication method used by nurses who are completing
care for a patient to transmit patient information to nurses who are about to assume
responsibility for continuing care; may be exchanged verbally in a meeting or
audiotaped
Charting by Exception ✅shorthand method for documenting patient data that is based
on well-defined standards of practice; "We don't chart unless something abnormal
happens or something went wrong."
Collaborative Pathway ✅case management plan that is a detailed, standardized plan
of care developed for a patient population with a designated diagnosis or procedure; it
includes expected outcomes, a list of interventions to be performed, and the sequence
and timing of those interventions
Focus Charting ✅a documentation system that replaces the problem list with a focus
column that incorporates many aspects of a patient and patient care; the focus may be
a patient strength or a problem or need; the narrative portion of focus charting uses the
data (D), action (A), response (R) format
Health Information Exchange (HIE) ✅allows for safe transmission of patients
confidential and data between providers
ISBAR communication ✅An effective hand-off of the patient to another health care
individual:
Identity/Introduction
Situation
Background
Assessment
Recommendation and then Read Back
Minimum Data Set ✅A standard established by health care institutions that specifies
the information that must be collected from every patient
PIE charting ✅documentation system that does not develop a separate care plan; the
care plan is incorporated into the progress notes in which problems are identified by
number, worked up using the:
(P)Problem of the patients
(I) Intervention or measures you took help the problem
(E) Evaluation of the outcomes of the nursing interventions
....format.
, Problem-Oriented Medical Record (POMR) ✅Documentation system organized
according to the persons specific health problems'includes database, problem list, plan
of care, and progress notes.
SOAP format ✅method of charting narrative progress notes, organizes data according
to:
(S)Subjective information
(O)Objective information
(A)Assessment
(P) Plan
Variance report ✅a report of any event that is not consistent with the routine operation
of the health care agency that results in or has the potential to result in harm to a
patient, employee, or visitor.
DARP charting ✅Data, Action, Response, Plan
All information about patients is considered private or confidential, whether written on
paper, saved on a computer, or spoken aloud. What is an example of breach of
confidentiality? ✅Failing to log off computer.
Never document interventions before... ✅carrying them out!
When to write a progress note ✅Upon admission, transfer to another unit and
discharge, when a procedure is performed, upon receiving patient postoperative or
post-procedure. Upon communicating with physicians regarding critical patient info
(abnormal lab result) and for any change in status of patient.
Which organization audits charts regularly? ✅The joint commission
The ultimate goal of health informatics is to improve the health and well-being of
✅Canadians
The nursing is caring for a client who requests to see a copy of his or her health care
records. What action by the nurse is most appropriate? ✅Review the hospital's
process for allowing clients to view their health care records
The nurse is caring for a client with hypertension, and only documents a blood pressure
of 170/100 mm Hg when all other vital signs are normal. This reflects what type of
documentation? ✅charting by exception
The nurse is documenting a variance that has occurred during the shift. This report will
be used for quality improvement to identify high-risk patterns and, potentially, to initiate
in-service programs. This is an example of which type of report? ✅incident report
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