Source oriented charting - Study guides, Class notes & Summaries

NFDN 1002 MIDTERM UNITS 1-4 QUESTIONS AND ANSWERS Intrapersonal Communication - Correct Answer ️️ -communication with oneself Interpersonal Communication - Correct Answer ️️ -between two or more people Transpersonal Communication - Correct Answer ️️ -interaction that occurs within a person's spiritual domain SOAP Charting - Correct Answer ️️ -S= Subjective data (how the patient feels) O= Objective data (results of physical exam, vital signs, etc) A= Assessment (what is t...

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...

Critical Thinking (definition)-  Critical thinking is required to use the nursing process successfully.• Critical thinking means requiring careful judgment.• Critical thinking is directed purposeful mental activity by which ideas are evaluated, plans are constructed, and desired outcomes are met Essential for evaluation purposes Clinical reasoning Charting by exception  use of predetermined standards and norms to record only significant assessment care Source-oriented  c...

What are the 5 steps in the nursing process? - Answer-Assessment Diagnosis Planning Implementation Evaluation What is the assessment portion of the nursing process used for? - Answer-data collection what is the nursing diagnosis portion of the nursing process used for? - Answer-analyzing the data what is the planning portion of the nursing process used for? - Answer-the steps to resolve the health problem present what is the implementation portion of the nursing process used for? - Answ...

1 FNP EXAM #3 REVIEW QUESTIONS AND ANSWERS, RATED A+ disadvantages and advantages with source-oriented medical record -Disadvantages: information scattered throughout record -Advantages: easy to find care provided Source-oriented record Contains 1. Admission data (demographics) 2. Advance directives (client wishes) 3. History and physical (problem, meds, allergies) 4. Labs 5. Graphic data 6. Notes Problem-oriented record contains: 1. Database problem list 2. Plan of care 3. Probl...

Nurs1000 – Documentation Exam Questions With 100% Verified Answers Standards of practice for nursing documentation - answermust be accurate, comprehensive, and flexible enough for members of the health care team to retrieve critical data, maintain continuity of care and track patient outcomes, and it must reflect current standards of nursing practice. confidentiality of nursing documentation - answera nurse is legally and ethically obligated to keep information about patients confidentia...

Describe the communication process - Stimulus, source (seder/encoder), message, channel, receiver (decoder), feedback/communication Identify factors that influence communication - Developmental level, gender, sociocultural differences, roles and responsibilities, space/territoriality, physical/mental/emotional state, values, environment Discuss types of communication used in healthcare and the role of the nurse in each type. - Verbal, nonverbal, electronic - Define therapeutic comm...

NFDN 1002 MIDTERM UNITS 1-4 2024 EXAM!!

Patients have the right to... - see and copy their health record - update their health record - get a list of disclosures - request a restriction on certain uses or disclosures - choose how to receive information Similar to a credit card that has a magnetic strip that contains vital emergency healthcare information or a link to healthcare info using pin number health care smart card Patient care record created when facilities under different ownership share their data; accessible to designated...

The nurse changes a dressing and observes a patient's wound has decreased in size. Where in a problemoriented medical record would the nurse chart this information? - Progress notes The nurse is reinforcing teaching to nursing students about the purposes of documentation. Which information should the nurse include? Select all that apply - Provides continuity of care Obtains reimbursement for care Serves as a record for quality assurance Serves as a legal record Which individualized interv...