NUR 155 EXAM ONE EXAM 2023 Full and Revised Study Guide with Complete solutions

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 accountability act 1996;amended 2003

•        Duty is to protect PHI- Protected health information

Computerized records:

•        Cerner

•        Epic

•        Meditech

Purpose of records (DRG) diagnosed related group

•        Communication, planning client care, research

•        Auditing, reimbursement, legal documentation

•        Education, health care analysis

Documentation Systems

•        Source oriented record: traditional, each department or individual has their own section

•        Narrative: component of source oriented, no right or wrong order;

chronological used

Problem Oriented medical record- POR

•        4 basic components:

•        Database: known when pt 1^st enters health care facility, nursing assessment, primary care history, social & family data, baseline physical exam & diagnostic test.

•        Problem list: derived from database. Caregivers contribute, physiological, psychological, social, cultural, spiritual,

development, and environmental needs. Medical problems, diagnoses, surgical procedures, symptoms; nurse diagnoses. (ex impaired mobility, urinary incontinence).

•        Plan of Care- Initial list of orders or plan of care.

•        Progress notes- chart entry’s made by ALL Health care professionals involved in patients care. SOAP or SOAPIER- Subjective- obtained from client, Objective-information measured or observed (vital signs, lab, x-ray). Assessment- conclusions drawn subjective and objective from data (clients condition and level of progress). Plan- plan designed to resolve stated problem. I- intervention, E- evaluation, R- revision.

PIE- Problems Interventions Evaluation

•        Consists or patient flow sheets and progress notes

DAR- Data Action Response

•        Focus charting- intended to make patient concerns and strengths the focus of care

CBE- Charting by Exception

•        Only abnormal or significant findings, exceptions to the norms recorded. 3 key elements: Flow sheets (vitals, head and face assessment) Standards of care- unconscious patient oral care q4h. Beside access chart forms- all flow sheets kept at patients bedside for immediate recording.

*Guidelines for recording

•        Date/ time

•        Legibility

•        Permanence-Ink

•        Accepted terminology

•        Signature, Accuracy and completeness

*SBAR

•        S- situation- state your name, unit, patient name, briefly state problem

•        B- background- admission diagnoses, medical history, summary

of tx to date, code status

•        A- assessment- vital signs, pain scale, change from prior assessment