Buscar
Estás en modo de exploración. debe iniciar sesión para usar MEMORY

   Inicia sesión para empezar

level: Level 1

Questions and Answers List

level questions: Level 1

QuestionAnswer
auditorspeople appointed to examine patient charts and health records to assess quality of care
chart(health care record)a legal record that is used to meet the many demands of the health, accreditation, medical insurance and legal systems
chartingprocess of recording information on a patient's chart
charting recording or documentingprocess of noting data in a patient record , usually as prescribed intervals
charting by exceptionrecording only new data or changes in a patient status or care; charting the exceptions to the previously recorded data
computer on wheels (COWs)POC systems are sometimes housed on wheeled carts
databasefrom the history, the physical examination and the diagnostic tests are used to identify and prioritize the health problems on the master medical and other problem lists
diagnosis related groups (DRGs)how hospitals get paid, cost reimbursement rates by government plans
documentinginvolves recording the interventions carried out to meet the patient's needs
electronic health record (EHRs)allows exchange of patient data not only within a facility but also from one facility to another
electronic medical record (EMRs)also referred as (EHRs)
informaticsthe study of information processing
Kardex (or RAND)system used by some facilities to consolidate patient orders and care needs in a centralized, concise way
narrative chartingrecording of patient care n descriptive form
nomenclaturea classified system of technical or scientific names and terminology
nursing care planoutlines the proposed nursing care based on the nursing care based on the nursing assessment and the identified patient problems to prove contimtusi
nursing notesform on the patient's chart on which nursed record observations, the care given
peer reviewan appraisal by professional coworkers of equal status
personal health record (PHR)an extension of the EHR that allows patients to input their information into an electronic database
point of care (POC)systems permit computer input only at the nurses' station; some facilities have bedside systems
problem listactive, inactive, potential, and resolved problems serve as the index for chart documentation
quality assurance, assessment, and improvementan audit in health care that evaluates services provided and the results achieved compared with accepted standards
recordingprocess of adding written information to the chart, usually at prescribed intervals
SBAR(situation, background, assessment, recommendation) a method of communication among health care workers and a part of documentation
SOAPEthe briefer adaptation of the charting format for the POMR
SOAPIER (SOAPE documentation)an acronym for seven different aspects of charting
What does SOAPIER stand for?subjective, objective, assessment, plan, intervention, evaluation, revision
traditional (block) chartdivided into sections or blocks; emphasis is placed on specific sections of information
assessmenta systematic, dynamic, way to collect and analyze data about a client, the first step in delivering nursing care
nursing processa systematic method by which nurses plan and provide care for patients
outcomessomething that person strives to achieve
What is nursing?protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy, in the care of individuals, families, groups, communities, and population
what does an assessment include?not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well
what are two types of assessments?Complete & Focus
complete assessmentinvolves a review and physical examination of all body systems
What is a focused assessment?is advisable when the patient is critically ill, disoriented, or unable to respond
What type of data are we collecting?Subjective and objective
cuea piece or pieces that often indicate that an actual or potential problem has occurred or will occur
subjective datainformation that is provided by patient
objective dataobservable and measurable signs
biographic dataprovide information about the facts or event's in a person life
diagnoseto identify the type and cause of a health condition
nursing diagnosis/patient problem statementa type of health problem that can be identified by the nurse
What is NANDA-Ito reflect nursing diagnosis terminology uses around
databasea large store or bank of information
Data Clusteringthe clustering of related data helps to identify patterns that assist with the identification of patient's health problems
patient problem statementsused to guide the development of a nursing care plan
Who's responsibility is the assessment and development of nursing diagnosis or patient problemsRN
If the nurse is not able to prescribe the primary treatment, then what?the problem is not a nursing diagnosis or patient problem
when identifying patient problems, consider what factors?patient's presenting signs and symptoms; contributing, etiologic (causative), and related factors; and defining characteristics
potential patient problemsare written as two part statements (1) patient problem statement with adjective "potential" in front of it (2)the risk factors
collaborative problemshealth-related problems that the nurse anticipates based on the condition or diagnosis of a patient
medical diagnosisthe identification of a disease or condition with evaluation of physical signs, symptoms, patient interview, laboratory tests, diagnostic procedures, review, laboratory tests, diagnostic procedures, review of medical records, and patient history
goalthe purpose to which an effort is directed
What should the goal statement start with?the patient WILL
what are measurable verbs ?indicates the precise behavior that the nurse anticipates hearing or seeing such as define, describe, list, walk, demonstrate, and verbalize
planningphase of the nursing process, priorities of care are established and nursing interventions are chosen to best address the patient problem statement
nursing interventionsactivities that promote the achievement of the desired patient goal
physician-prescribed interventionsactions ordered by the physician for a nurse or health care professional to perform
nurse prescribed interventionsany actions that a nurse is legally able to order or begin independently
once patient problems have been identified the RN must prioritized the patient problem according to the the patent's current health status by using _____Maslow's Hierarchy of needs
implementationphase of the nursing process, the nurse and other members of the team put the established into action to promote goal achievement
evaluationa determination made about the extent to which he established goals have been achieved
includes the subject, action verb, and qualifying details; must be easy to interpret, very specificwritten nursing interventions
standardized languageterms that have the same definition and meaning regardless of who uses them
nursing sensitive patient outcomesresults of outcomes of nursing interventions. these outcomes or indicators are influenced by nursing and can be used to judge effectiveness of care and determine best practices
managed carerefers to health care systems that have control over primary health care services and attempt to trim down health care costs by reducing unnecessary or overlapping services; an emphasis is placed on health promotion, education, and preventive medicine
What are the 5 purposes for keeping patient records?Accountability, Documented communication, legal record of care, teaching, & research/data collection
what is the nursing process?Assessment, diagnosis, planning, outcome identification, implementation, evaluation
assessmentcollecting & analyzing data of patient
diagnosisidentifying type & cause of health condition
outcome identificationindividualized goals or expected outcomes associated with the nursing diagnosis
planningpriorities of care established interventions are chose
implementationperform the action identified in planning
evaluationdetermine if goals met and outcomes achieved
what is the patient chart considered?a legal document
what does the extra R in SBARR stand for?Read back
what is required for a nursing license?need to know guidelines of documentation
If it wasn't documentedIt didn't happen
How long do you have to stay in a facility in order for insurance to cover it?short term stay, at least 3 nights
Using SBAR format, what do you do when receiving a doctor's order over the phone?Always clarify with the doctor about the order given
EHRinfo goes straight to pharmacy, also used to order diagnostic tests
What time should only be used in nursing notes?military
In nursing notes you never include what?incident reports
SOAP notes are considered?problem oriented
The lower the acuity # means?the higher the care
Method of RecordingTraditional Chart (Block Charting)
Narrative ChartingDescriptive Form
Focus Charting FormatD.A.R.E.
What does D.A.R.E stands for?Data, Action, Response, Evaluation
Clincal Pathwaysallows staff from all disciplines to develop standardized, integrated care plans for a longer length of stay for patients of a specific case type
OBRA(Ombinus Budget Reconciliation Act)signifies medicare & medicaid requirements for long term care
property of the institution or the health care provideroriginal health care record
what does a patient has to do to gain access to their health records?follow established policy
What must a student nurse or nurse NEVER do?no information or documents stating patients' info should be left behind, alone or shared
What is evidence-based?nursing research
The framework to organize individualized nursing carenursing process
Thinking with a purpose iscritical thinking
Primary sourcepatient only source of data
Secondary sourcethe rest involved
What is data clustering?defining characteristics
Nandadefinition of nursing diagnosis terminology
medical diagnosisidentification of the disease
variancewhen a patient doesn't achieve patient outcome
What are SMART goals?specific, measurable,attainable, realistic, timing