NSC 114 Exam 2 Questions with Complete Solutions
Ethical and legal considerations - Answer-- Confidentiality of all patient information
- Client's record protected legally as a private record of client's care
- HIPAA regulations
- Responsibility in using records for the purpose of education ...
NSC 114 Exam 2 Questions
with Complete Solutions
Ethical and legal considerations - Answer-- Confidentiality of all patient information
- Client's record protected legally as a private record of client's care
- HIPAA regulations
- Responsibility in using records for the purpose of education and research
- dont chart for another nurse
- do not leave computer unattended
- only look at your pts charts
Purposes of Client Records - Answer-*communication - prevents delay in care
*planning client care - nurses use baseline and ongoing data to evaluate effectiveness
of the care plan
* auditing health agencies - review client records for quality assurance purposes
SAPT planning and goal setting - Answer-S- subject (always client)
A - action verb (will have)
P - performance criteria (no pain)
T - target time (by end of shift)
What not to document - Answer-* opinions
* assumptions
* for other health care professionals
* not about you its about PT
* judgemental terms
*dont make accusations
* dont state an error was made
documentation rules for paper - Answer-* do not leave a blank line above signature
* for late entries label with the time the note was written and begin with the words late
entry, and document the time the even occurred
* draw line and put error for wrong charting and initial corrections
Assertive nurse - Answer-maintain eye contact
speak firmly and clearly
project a clear tone of voice
focus on issues
maintains professional composer
speaks genially without sarcasm
,techniques to enhance communication among teams - Answer-SBAR
Call Out (method to communicate important info during a critical event)
Check Back (closes communication loop, verifies and validates information exchanged
reduces communication appointments)
Hand Off (method of sharing information when team members change)
factors affecting learning - Answer-- Age and developmental stage
- Motivation - Readiness - Active involvement
- Relevance - Feedback - Nonjudgmental support
- Simple to complex learning - Repetition - Timing
- Environment - Emotions - Physiological events
- Cultural aspects - Psychomotor ability
source-oriented record - Answer-paper format in which each health care group keeps
data on its own separate form
Narritive Charting - Answer-traditional part of the source-oriented record.
consist of written notes that include routine care, normal findings, and client problems.
POMR - Answer-Problem
Oriented
Medical
Records
***Divides records into four sections ***
**Data base (consist of all information known about the client)
**Problem list (is derived from the database. it is usually kept at the front of the chart
and serves as an index to the numbered entries in the progress notes)
** Plan of care (the initial list of orders or plan of care is made with reference to the
active problems)
* *Progress notes (chart entry made by all health professionals involved in a client's
care)
Progress notes form of charting in POMR - Answer-SOAP
S - Subjective data (consist of information obtained from what the client says)
O - Objective data (consist of information that is measured or observed by use of the
senses ex. vital signs)
A - Assessment (interpretation or conclusions drawn about the subjective and objective
data)
P - Plan (the plan of care designed to resolve the stated problem)
PIE charting - Answer-method of recording the client's progress under the headings of
problem, intervention, and evaluation
P - problem
I - intervention
E - evaluation
, Focused Charting (DAR) - Answer-data, action, response
occurs a lot in ER
progress notes
Charting by exception (CBE) - Answer-Documentation system in which only abnormal
or significant findings are recorded
1. Flow sheets - (example of flow sheets include graphic records of vital sign sheet, a
head and face assessment in a daily nursing assessment record)
2. standards of nursing care
3. bedside access to chart forms
Kardexes - Answer-Series of cards kept in a portable index file or on computer-
generated form that makes information quickly accessible
widely used, concise method of organizing and recording data about a client, making
information quickly accessible to all health professionals.
intake and output record - Answer-all routes of fluid intake and all routes of fluid loss or
output are measured and recorded on this form
I&O
MAR - Answer-include medication order, expiration date, medication name, and dose,
frequency of administrate and route, and nurses signature. allergies
M - medication
A - administration
R - record
skin assessment record - Answer-EHR - specifically utilizes braden assessment
include categories related to stage of injury, drainage, odor, culture information, and
treatments.
Nursing Discharge/Referral Summaries - Answer-completed when the client is being
discharged and transferred to another institution or home setting.
* * description of client's mental, physical, and emotional status at discharge or transfer
* * resolved health problems
* * unresolved continuing health problems
* * treatments that are to be continued
* * current meds
* * restrictions
* * functional self care abilities in terms of vision, hearing, speech mobility
* * comfort level
* * support people
* * client education
Voordelen van het kopen van samenvattingen bij Stuvia op een rij:
Verzekerd van kwaliteit door reviews
Stuvia-klanten hebben meer dan 700.000 samenvattingen beoordeeld. Zo weet je zeker dat je de beste documenten koopt!
Snel en makkelijk kopen
Je betaalt supersnel en eenmalig met iDeal, creditcard of Stuvia-tegoed voor de samenvatting. Zonder lidmaatschap.
Focus op de essentie
Samenvattingen worden geschreven voor en door anderen. Daarom zijn de samenvattingen altijd betrouwbaar en actueel. Zo kom je snel tot de kern!
Veelgestelde vragen
Wat krijg ik als ik dit document koop?
Je krijgt een PDF, die direct beschikbaar is na je aankoop. Het gekochte document is altijd, overal en oneindig toegankelijk via je profiel.
Tevredenheidsgarantie: hoe werkt dat?
Onze tevredenheidsgarantie zorgt ervoor dat je altijd een studiedocument vindt dat goed bij je past. Je vult een formulier in en onze klantenservice regelt de rest.
Van wie koop ik deze samenvatting?
Stuvia is een marktplaats, je koop dit document dus niet van ons, maar van verkoper Scholarsstudyguide. Stuvia faciliteert de betaling aan de verkoper.
Zit ik meteen vast aan een abonnement?
Nee, je koopt alleen deze samenvatting voor €13,35. Je zit daarna nergens aan vast.
