Documentation formats - Study guides, Class notes & Summaries

What is the purpose of documentation? : Facilitating communication among team members. Creating a legal report of care delivery. Providing consistent care from shift to shift. Improving the facility's care quality. What are some common charting formats? : - SOAPIE - Focus charting - Narrative - Problem / intervention / evaluation 2 - Exception What are some advantages of electronic records? : - Saves time for nurses - less repetition - more accurate - can be used by multiple peo...

client documentation correct answers -IF IT IS NOT WRITTEN DOWN IT DIDN'T HAPPEN - includes: assessmtn summaries, treatment to program plans, progress notes, discharge/referral summaries -document connections between program goals, client goals and client program involvement and client outcomes -in all cases, documentation and written records should focus on client behavior, rather than the specialists perceptions or guesses -in each case, the specialist is responsible for selecting the mso...

Intro To HIM Final Study Guide Practice Test 2024. What is the national association for HIM professionals? - correct answer AHIMA - American Health Information Management Association. What is the role of the HIM professional within the healthcare organization? - correct answer 1. Conducting a data content standards requirements analysis 2. Developing a local data dictionary to support enterprise-wide interoperability 3. Advancing the development of data content standards 4. Contributing t...

CCA Exam Questions & Answers 2023/2024 An encounter that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n) - ANSWER-logic-based encoder The best resource for checking out specific voluntary accreditation standards and guidelines for a rehabilitation facility is the - ANSWER-CARF Manual You have been asked to give an example of a clinical information system. Which one of the following would you cite? A. Fina...

5/3/19 ATI FUNDAMENTALS EXAM 1. CHAPTER 1: HEALTH CARE DELIVERY SYSTEMS A. Components of Health care systems a. Participants 1. Consumers- clients 2. Providers a. Licensed providers: registered nurses, license practical (or vocational) nurses (LPN), advanced practice nurses (APN), medical doctors, pharmacists, dentists, dietitians, physical/respiratory/occupational therapists, etc b. Unlicensed providers: assistive personal b. Settings 1. Hospitals, homes, skilled nursing, assisted living, schoo...

(3) AORN PeriOp 101 Exam (Perianesthesia Nursing; Anesthesia; Specimens; Medications & Solutions) 2024 Perianesthesia Nursing includes - ANSWER-Preadmission Testing Unit (PAT) PreOp Care Unit PreOp Holding Post-anesthesia Care Unit (PACU) Extended Care Unit Phase 1 post-anesthesia care - ANSWER-1. Airway 2. Monitor for BP, O2 sat 3. HR 4. LOC 5. Pain and PONV (post-operative N/V) The _____ amount of time to pre-warm the patient prior to anesthesia to avert hypothermia is _____. - AN...

A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on exertion." Which of the following documentation formats describes this entry? The "I" in PIE. The "S" in SOAP. The "R" in DAR. The "E" in PIE. 1 of 20 Term A nurse manager is reviewing the documentation of four newly licensed nurses. Which fo the following medication enteries should the nurse identify as being written correctly? Synthroig 100 mg PO every morning ac E...

HIM Chapter 6 Data Management Set 1 data - correct answer is a representation of basic facts and observations about people, processes, measurements and conditions healthcare specific data - correct answer focuses on pts whic include demographic, financial, and clinical data data management - correct answer refers to the definition and structure of data elements and the creation, storage and transmission of data elements. effective oversight and mgmt of data is an essential part of day ...

(3) AORN PeriOp 101 Exam (Perianesthesia Nursing; Anesthesia; Specimens; Medications & Solutions) 2024 Perianesthesia Nursing includes - ANSWER-Preadmission Testing Unit (PAT) PreOp Care Unit PreOp Holding Post-anesthesia Care Unit (PACU) Extended Care Unit Phase 1 post-anesthesia care - ANSWER-1. Airway 2. Monitor for BP, O2 sat 3. HR 4. LOC 5. Pain and PONV (post-operative N/V) The _____ amount of time to pre-warm the patient prior to anesthesia to avert hypothermia is _____. - AN...

What is the purpose of documentation? - Answer-Facilitating communication among team members. Creating a legal report of care delivery. Providing consistent care from shift to shift. Improving the facility's care quality. What are some common charting formats? - Answer-- SOAPIE - Focus charting - Narrative - Problem / intervention / evaluation - Exception What are some advantages of electronic records? - Answer-- Saves time for nurses - less repetition - more accurate - can be used ...