Charting by exception Study guides, Class notes & Summaries

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...

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 ...

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...

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...

MN Jurisprudence Exam Latest Update Graded A+ perform preliminary charting of he oral cavity and surrounding structures to include case histories, perform initial and periodic examinations and assessment to determine periodontal status. and formulate a dental hygiene plan in coordination with the dentists treatment plan. DH- general complete preliminary charting of the oral cavity and surrounding structures with the exception of periodontal probing and assessment of the periodontal ...

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...

MN Dental Assistant Jurisprudence Exam with Complete Solutions General The dentist has prior knowledge and has given consent for the procedures being performed during which the dentist is not required to be present in the dental office or on the premises. Indirect The dentist is in the office, authorizes the procedures, and remains in the office while the procedures are being performed by the allied dental personnel. Direct The dentist is in the dental office, personally diagnoses t...

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 ...

*General supervision - The dentist has prior knowledge and has given consent for the procedures being performed during which the dentist is not required to be present in the dental office or on the premises. *Indirect - The dentist is in the office, authorizes the procedures, and remains in the office while the procedures are being performed by the allied dental personnel. direct - The dentist is in the dental office, personally diagnoses the condition to be treated, personally authorizes ...

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...