NU 309: Documentation and Interdisciplinary
Communication Questions With Complete Solutions
Admission assessment Correct Answers -Nurse conducts
-Often referred to as nursing H & P
-Within 24 hours to 3 days dependent on facility
-Comprehensive information about the client's physical,
psychological, functional, social, and spiritual abilities
-Care providers can refer to this initial assessment to obtain
important baseline info
-When pt. is admitted you begin building a plan of care. A
thorough assessment is necessary to accomplish this.
-In the hospital setting, you typically see the admission
assessment completed immediately or shortly after arrival.
Batch charting Correct Answers -waiting until end of shift or
until all pt. have been assessed
-Lots of room for error
-Electronic charting will always show current time when you
chart, but the time may be changed in the system to the time the
assessment was actually performed
Chart; do Correct Answers If you didn't _____ it, you didn't __
it.
Charting by exception Correct Answers -type of progress notes
-Predetermined standards and norms to record only significant
assessment data
-unexpected findings require additional documentation
, Clinical pathway Correct Answers Multidisciplinary tool that
identifies a standard plan for a specific client population
Communication Correct Answers includes verbal and
nonverbal
Confidentiality Correct Answers -keeping information private
-HIPAA
-what happens at clinical, stays at clinical
-NEVER take personal information away from clinical site
-DO NOT look at charts of a pt. you are not directly caring for
-No discussion of pt. in hall, elevator, cafeteria, etc.
Critical thinking and clinical judgement Correct Answers all
nurses use this to determine if abnormal assessment data is
significant
DAR notes Correct Answers -type of progress notes
-broad view
-works well for long-term care
-may be difficult to identify chronological order and may not
relate to point of care
-(D) Data (A) Action (Response)
Discharge note Correct Answers -Discharge teaching,
medications, when to contact provider, condition at discharge,
time of discharge
-always get a set of vitals before discharging a pt. Give client a
copy of discharge teaching and summary.
Documentation Correct Answers _____________ must be:
Communication Questions With Complete Solutions
Admission assessment Correct Answers -Nurse conducts
-Often referred to as nursing H & P
-Within 24 hours to 3 days dependent on facility
-Comprehensive information about the client's physical,
psychological, functional, social, and spiritual abilities
-Care providers can refer to this initial assessment to obtain
important baseline info
-When pt. is admitted you begin building a plan of care. A
thorough assessment is necessary to accomplish this.
-In the hospital setting, you typically see the admission
assessment completed immediately or shortly after arrival.
Batch charting Correct Answers -waiting until end of shift or
until all pt. have been assessed
-Lots of room for error
-Electronic charting will always show current time when you
chart, but the time may be changed in the system to the time the
assessment was actually performed
Chart; do Correct Answers If you didn't _____ it, you didn't __
it.
Charting by exception Correct Answers -type of progress notes
-Predetermined standards and norms to record only significant
assessment data
-unexpected findings require additional documentation
, Clinical pathway Correct Answers Multidisciplinary tool that
identifies a standard plan for a specific client population
Communication Correct Answers includes verbal and
nonverbal
Confidentiality Correct Answers -keeping information private
-HIPAA
-what happens at clinical, stays at clinical
-NEVER take personal information away from clinical site
-DO NOT look at charts of a pt. you are not directly caring for
-No discussion of pt. in hall, elevator, cafeteria, etc.
Critical thinking and clinical judgement Correct Answers all
nurses use this to determine if abnormal assessment data is
significant
DAR notes Correct Answers -type of progress notes
-broad view
-works well for long-term care
-may be difficult to identify chronological order and may not
relate to point of care
-(D) Data (A) Action (Response)
Discharge note Correct Answers -Discharge teaching,
medications, when to contact provider, condition at discharge,
time of discharge
-always get a set of vitals before discharging a pt. Give client a
copy of discharge teaching and summary.
Documentation Correct Answers _____________ must be:
