Charting by exception - Study guides, Class notes & Summaries

A method of documenting nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called: a. Problem-oriented progress notes b. Charting by exception c. Consultative notations d. Open charting - Charting by exception Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's h...

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 tha...

Part of diagnostic reasoning. The process of drawing conclusions from related pieces of evidence and previous experience with evidence - Clinical inference Classifications based on a patients primary and secondary medical diagnosis that are used as the basis for establishing Medicare reimbursement for patient care. - Diagnosis-related groups (DRGs) A combination of hardware and software that protects private network resources - Firewall A system of organizing documentation to place primary ...

Perform preliminary charting of oral cavity and surrounding structures including case histories, initial and periodic examinations, determine perio status, formulate dental hygiene treatment, coordinate with dentist for treatment plan DH General supervison Complete preliminary charting of the oral cavity and surrounding structures with the exception of periodontal probing and assessment of perio structure LDA General Supervison Obtain informed consent within scope of practice. DH/LDA genera...

PCC Final Exam 2 Questions with 100% Correct Answers 2024/2025 -recording -communication -reimbursement -quality improvement -accreditation -research -educational tool - ANSWERSWhat are the purposes of the patient chart/record? beginning of shift, throughout shift, end of shift - ANSWERSWhen should you review the chart? source-oriented system - ANSWERS•Disciplines charted separately •Variety of sections (e.g., admission, H&P, diagnostic, graphic, nurses' notes, progress no...

Ch 16, 19 Identify the purposes of the client record - Communication among health professionals, Education of health professionals, Legal documentation detailing the client's care, Quality assurance, Identification of the cost of care, Health research What are the key differences between source-oriented and problem-oriented records? - The source-oriented record is organized according to discipline. Each discipline charts in its defined section of the chart. The problem-oriented record is or...

HESI PRACTICE ACTUAL EXAM Questions and Answers (2024 / 2025) (Verified Answers).1. The nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. Why is this an incorrectly stated diagnosis statement ANS It identifies the medical diagnosis instead of the patient's response to the diagnosis 2. Nurses in the presurgical unit are preparing patients with different medical conditions for surgical pr...

Perform preliminary charting of the oral cavity and surrounding structures to include case histories, perform initial and periodic examinations and assessments to determine periodontal status, and formulate a dental hygiene treatment plan in coordination with a dentist's treatment plan. - Answer DH - General Complete preliminary charting of oral cavity and surrounding structures with exception of periodontal probing and assessment of the periodontal structure. - Answer LDA - General ...

Perform preliminary charting of the oral cavity and surrounding structures to include case histories, perform initial and periodic examinations and assessments to determine periodontal status, and formulate a dental hygiene treatment plan in coordination with a dentist's treatment plan. - DH - General Complete preliminary charting of oral cavity and surrounding structures with exception of periodontal probing and assessment of the periodontal structure. - LDA - General Make referrals to d...

WGU C810 HIPPA Health records Management Exam proficiency Guide Questions with Approved Solutions 2024/2025 Which Classification system was established for the prospective reimbursement of a covered home care services to Medicare beneficiaries during a 60-day episode of care? - correct answer HHRG's Which relative value unit takes into account the operational costs of delivering healthcare services, such as rent, wages of technical personnel, supplies, and equipment? - correct answer Prac...