Charting by exception - Study guides, Class notes & Summaries

PNR 104 Exam 2 (Answered) Verified Solution Steps of the nursing process in order Assessment, nursing dx, planning, implementation, and evaluation Assessment and nursing DX RN's are responsible for this part of the nursing process Data Collection LPN's main role in nursing process Documentation of the plan Should be constructed right after the admission database is collected. Must be readily available to each nurse who is assigned to the patient. (Reviewed & updated once every 24 hrs.)...

4 common issues in malpractice caused by inadequate documentation are - not charting the correct time when events occurred, failing to record verbal orders or failing to have them signed, charting actions in advance to save time, documenting incorrect data 7 pillars of TIGER initiative - 1. management and leadership 2. education 3. communication and collaboration 4. informatics design mation technology 6. policy 7. culture accreditation - joint commission mandates admission database - chie...

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...

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 - B A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis...

Nurs- B260 Fundamentals Exam 2 Questions with Complete Solutions Medical Record - Correct Answer Purpose: -Facilitate interdisciplinary communication, provide a record of care, allow for auditing, monitoring, and evaluation of care provided. Also serve as sources of research data and learning resources -Used for communication, legal documentation, reimbursement for health care services, auditing and monitoring (to see if standards of care were met) Guidlines for Quality Documentation - Cor...

Change-of-shift Report - Answer 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 (CBE) - Answer shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes

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...

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...

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 - B A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, an...

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...