Soapier charting - Study guides, Class notes & Summaries

NUFT 204 Exam Questions and Answers Latest Updated 2024/2025 (100% Solved) Current health or history of current illness - HPI (history of present illness 4.Past health 5.Family history 6.Review of systems - Head to toe 7.Functional assessment or ADLs " Examples of Biographical data in health hstory - ANSWER "Name •Address and phone number •Age and birth date •Birthplace •Sex •Marital status •Race •Ethnic origin •Occupation—usual and present •Source of informa...

NUR 155 Exam 1 Documentation (Ch. 15) Questions and Answers Source-Oriented Records - Answer ️️ -One in which each healthcare group keeps data on its own separate form. Sections designed for nurses, physicians, lab, x-ray, etc. Source-Oriented Records - Answer ️️ -Each discipline can easily find and chart pertinent data is an example of an advantage of what? Source-Oriented Records - Answer ️️ -Fragmented data -- making it difficult to track problems chronologically with input...

NUR 155 Exam 1 Documentation (Ch. 15) Questions and Answers Source-Oriented Records - Answer ️️ -One in which each healthcare group keeps data on its own separate form. Sections designed for nurses, physicians, lab, x-ray, etc. Source-Oriented Records - Answer ️️ -Each discipline can easily find and chart pertinent data is an example of an advantage of what? Source-Oriented Records - Answer ️️ -Fragmented data -- making it difficult to track problems chronologically with input...

NUR155 EXAM ONE STUDY GUIDE Exam One Study Guide With Complete Solutions Documenting and Reporting: Chart For everyone to see that is caring for patient, only look at charts of patients you need to know about. • can be formal or informal • oral written or computerized • chart is a legal record Legal considerations: • chart is legally protected • organization owns • patient has rights to chart • restricted access HIPPA: • Health insurance portability and accountabilit...

Source-Oriented Records One in which each healthcare group keeps data on its own separate form. Sections designed for nurses, physicians, lab, x-ray, etc. Source-Oriented Records Each discipline can easily find and chart pertinent data is an example of an advantage of what? Source-Oriented Records Fragmented data -- making it difficult to track problems chronologically with input from different groups of professionals data is an example of a disadvantage of what? Narrativ...

NUR 155 Exam 1 Documentation (Ch. 15) Questions and Answers Source-Oriented Records - Answer ️️ -One in which each healthcare group keeps data on its own separate form. Sections designed for nurses, physicians, lab, x-ray, etc. Source-Oriented Records - Answer ️️ -Each discipline can easily find and chart pertinent data is an example of an advantage of what? Source-Oriented Records - Answer ️️ -Fragmented data -- making it difficult to track problems chronologically with input...

Chapter 10: Documentation, Electronic Health Records, and Reporting MULTIPLE CHOICE 1. The nurse understands the need for accurate documentation due to which fact? a. Accurate documentation is needed for proper reimbursement. b. Accurate documentation must be electronically generated. c. Accurate documentation does not include e-mails or faxes. d. Accurate documentation is only accepted in court if written by hand. ANS: A Accurate documentation is necessary for hospitals to be reimbursed...

NUR155 EXAM (1)ONE STUDY GUIDE Exam One Study Guide With Complete Solutions Documenting and Reporting: Chart For everyone to see that is caring for patient, only look at charts of patients you need to know about. • can be formal or informal • oral written or computerized • chart is a legal record Legal considerations: • chart is legally protected • organization owns • patient has rights to chart • restricted access HIPPA: • Health insurance portability and accountabi...

NSG 3130 Final Competency Certification Study Guide Exam Questions with Certified for Accuracy Answers 2024/2025 Nurse would look at - correct answer - physiological - acute - unstable - unpredictable patients What you can delegate - correct answer - psychological patients - chronic patients - stable patients - predictable patients Documenting - correct answer documenting should be clear, and do not sign on anyone's charts. If it wasnt documented it didnt happen. Make s...