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NURS 122 Lecture WEEK 1 Verified Study Solutions With Latest Tests

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NURS 122 Lecture WEEK 1 Verified Study Solutions With Latest Tests discussion ANS an informal oral consideration of a subject by two or more healthcare personnel to identify a problem or establish strategies report ANS oral, written, or computer-based communication intended to convey informat...

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  • October 24, 2024
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  • 2024/2025
  • Exam (elaborations)
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  • NURS 122
  • NURS 122
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NURS 122 Lecture WEEK 1 Verified Study Solutions
With Latest Tests
discussion ANS an informal oral consideration of a subject by two or more healthcare personnel
to identify a problem or establish strategies



report ANS oral, written, or computer-based communication intended to convey information to
others



The process of making an entry on a patient record is called ANS recording, charting, or
documenting



clinical record ANS a formal, legal document that provides evidence of a patient's care



"The nurse has a duty to maintain confidentiality of all patient information" is said by who? ANS
The American Nurses Association (ANA) Code of Ethics



PHI is the abbreviation for ANS Protected Health Information



purposes of patient records include ANS communication, planning patient care, auditing health
agencies, research, education, reimbursement, legal documentation, healthcare analysis



the traditional patient record is called ANS a source-oriented record



narrative charting consists of what? ANS Written notes which include routine care, normal
findings, and patient problems



examples of diagnostic reports are ANS laboratory reports, x-ray reports, CT scan reports



examples of consultation reports are ANS physical therapy and respiratory therapy

, the abbreviation for POMR is ANS problem-oriented medical record



what is a POMR? ANS data is arranged according to the problems the patient has rather than
according to the source of the information



what are some advantages and disadvantages of a POMR? ANS advantages: they encourage
collaboration, and that the problem list in the front of the chart alerts caregivers to the patient's needs,
making it easier to track the status of each problem


disadvantages: not all caregivers can use the charting format effectively, constant vigilance is
required to maintain an up-to-date problem list which can be inefficient


what is a database? ANS all information known about the patient



SOAP is an acronym for ANS subjective, objective, assessment, and planning



subjective data ANS what the person says about himself or herself during history taking



objective data ANS information that is seen, heard, felt, or smelled by an observer; signs



assessment ANS interpretation or conclusions drawn about the subjective and objective data



interventions ANS actions taken to correct or manage a patient's problems



evaluation ANS patient responses to nursing interventions and medical treatments



revision ANS care plan modifications suggested by the evaluation

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