NUR 231 Exam 3 Practice Questions and Correct Answers
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Course
NUR 231
Institution
NUR 231
Guidelines for effective documentation. (Ch.19) Enter information in a complete, accurate, concise, current and factual manner. Make sure documentation reflects the nursing process and professional responsibilities. Record patient findings rather than your interpretation of these findings. Note pro...
NUR 231 Exam 3 Practice Questions and
Correct Answers
Guidelines for effective documentation. (Ch.19) ✅Enter information in a complete,
accurate, concise, current and factual manner. Make sure documentation reflects the
nursing process and professional responsibilities. Record patient findings rather than
your interpretation of these findings. Note problems as they occur in order. Avoid
stereotypes when charting. Refrain from copying and pasting notes in an EHR.
Document in a timely manner. Document interventions as closely as possible to
execution. Do not document interventions before carrying them out. Use standard
terminology and date and time each entry. Sign initial, last name, and title to each entry.
Recognize patient record is permanent. Understand patients have moral and legal right
to confidentiality.
Identify measures to protect confidential patient information. (Ch. 19) ✅Make sure
display screens do not face public areas. Use encryption software when sending e-mail
over public networks. Request that your unit have a separate printer not shared with
another unit. Use secure disposal containers adjacent to copies. Use phones with built-
in encryption technology. Before transmission, verify the fax number and that the
recipient is authorized to receive confidential information. Restrict use of voice pagers to
nonconfidential messages.
Describe the purposes of patient records. (Ch.19) ✅Communication- the primary
purpose to help health care professionals from different disciplines communicate with
one another. Diagnostic and therapeutic orders- diagnostic studies ordered for the
patient since admission, the results of these studies, and related orders for care. Care
Planning- patient's baseline and ongoing data and how the patient is responding to the
treatment plan from day to day. Quality Process and Performance Improvement-
evaluate the quality of care patients have received and the competence of nurses
providing the care. Research- studying patient records to learn how best to recognize or
treat identified health problems from the study of similar cases. Decision Analysis-
information from the record that provides the data needed by administrative strategic
planners to identify needs. Education- learning about particular health problems,
effective treatments, and factors affecting goal achievement from the patient's record.
Credentialing, Regulation, and Legislation- monitoring health care facilities compliance
with standards governing provision of care. Legal Documentation- patient records are
legal documents that might be used a evidence for court proceedings. Reimbursement-
patient records are used to demonstrate to payers that patients received the intensity
and quality of care. Historical Documentation- the records are dated so they have
historical content.
Compare and contrast different methods of documentation, including electronic health
records, source-oriented records, problem-oriented medical records, PIE charting, focus
charting, charting by exception, and the case management model. (Ch. 19)
, ✅Electronic Health Records- (1) provide accurate, up-to-date, and complete
information about patients at the point of care. (2) enable quick access to patient
records. (3) securely sharing electronic information. (4) improves patient and provider
interaction. (5) enhances privacy ad security. (6) improves efficiency and reduces cost
through decreased paperwork.
Source-Oriented Records- Paper format in which each health care group keeps data on
its own separate form. Advantage- each discipline can easily find and chart pertinent
data. Disadvantage- data are fragmented, making it difficult to track problems
chronologically with input from different groups of professionals.
Problem-Oriented Medical Records- Organized around patient problems rather than
around sources of information. All health care professionals record information on the
same forms. Advantages- entire health care team works together in identifying a master
list of patient problems and contributes collaboratively to the care plan.
SOAP Format- Subjective, Objective, Assessment, Plan is used to organize entries in
the progress notes of the POMR. Some nurses believe it focuses on too narrow of
problems.
PIE Charting- A patient assessment is performed and documented at the beginning of
each shift using pre printed fill in the blank assessment forms (flow sheets). Problem,
Intervention, Evaluation. An advantage is it promotes continuity of care and saves time
because there is not a separate care plan. Disadvantage- not having a formal care plan
causes the nurse to to read all the nursing notes to determine problems.
Focus Charting- to bring the focus of the care plan back to the patient and patient's
concerns. Advantage- holistic emphasis on the patient and the patient's priorities and
also ease of charting. Some nurses report that the DAR categories are ar
Describe effective reporting. (Ch. 19) ✅ISBAR
Identity/Introduction- communicate who you are, where you are, and why you are
communicating.
Situation- Communicate what is occurring and why the patient is being handed off to
another department or unit.
Background- Explain what led up to the current situation and put in context if necessary.
Assessment- Give your impression of the problem.
Recommendation- Explain what you would do to correct the problem.
Summarize the theories that describe how and why aging occurs. (Ch. 23) ✅Genetic
Theory- Lifespan depends to a great extent on genetic factors. Genes within the
organism control genetic clocks, they determine the occurrence rate of metabolic
processes.
Non-endocrine and Immunity Theories- Focuses on the functions of the immune
system. It seeks out and destroys foreign agents. The immune response declines
steadily after younger adulthood as the thymus loses size and function.
Stochastic Theories- based on the idea that there is a randomness to cellular and errors
that makes predicting aging and death impossible. Ex- wear and tear theory which
organisms wear out from increased metabolic functioning and cells become exhausted
from constant energy depletion.
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