FPCC - JACOBS – DOCUMENTATION REVIEW TEST QUESTIONS WITH REVISED AND UPDATED ANSWERS
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FPCC - JACOBS
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FPCC - JACOBS
FPCC - JACOBS – DOCUMENTATION REVIEW TEST QUESTIONS WITH REVISED AND UPDATED ANSWERS
MAR (Medication Administration Record) - Answer-What has been prescribed
Inpatient also tracks administration
Kardex - Answer-In the past, first place to look for quick info on client's care
Not permanent...
FPCC - JACOBS – DOCUMENTATION
REVIEW TEST QUESTIONS WITH
REVISED AND UPDATED ANSWERS
MAR (Medication Administration Record) - Answer-What has been prescribed
Inpatient also tracks administration
Kardex - Answer-In the past, first place to look for quick info on client's care
Not permanent part of patient's health record
Integrated Plan of Care Form - Answer-A combined charting and Care Plan form
"Occurrence" - Answer-An event we didn't expect to happen, Plan for, or hope for.
Reasons to report an "occurrence" - Answer-Analyze the event
Identify area for quality improvement
Formulate strategies to prevent
Where is the occurrence report placed in client's EHR? - Answer-It is not placed in the
client's EHR
Placed in a different electronic record
Hand-off Report - Answer-Change of shift
Handover to next nurse shift
Receiving nurse alerted to status or changes to planning
Bedside Hand-Off - Answer-Walking rounds
Introduction to patient and beginning of receiving nurse's assessment
Patient can participate
Face to Face (Oral) Hand-Off - Answer-Out-coming and In-coming Nurse
Whole shift
Time efficient
Recorded Report (Hand-off) - Answer-Audio recording for receiving nurse
Rounds can be continuous if planned properly
Two examples of oral reporting formats - Answer-PACE
SBAR
What shouldn't be included in a hand-off report? - Answer-Anything to prejudice the
receiving nurse against the client
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