PCC Final Exam 2 Questions with 100% Correct Answers 2024/2025
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Course
PCC
Institution
PCC
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 - ANSW...
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 notes, lab, rehab,
DC plan, etc.)
•Data scattered; may lead to fragmentation
problem-oriented system - ANSWERS•Organized around patient problems
•Four components
•Allows greater collaboration
-database
-problem list
-plan of care
-progress notes - ANSWERSWhat are the 4 components of a problem-oriented system?
charting by exception - ANSWERS•Chart only significant findings/Exceptions to norms
, •Drop-down boxes and checklists help to streamline charting
•Document all nursing actions in response to clinical issues and patient responses
-know what "normal" is, do not just follow previous shift
-If NOT normal: document specifically what you observed - ANSWERSWhat caution should you use while
using check boxes in Charting by Exception?
face sheet - ANSWERScontains patient demographic data
Patient care summary - ANSWERSContains CODE STATUS, Medical diagnosis, allergies, safety
precautions, isolation
Flow sheet - ANSWERSContains Vital signs, I&O, ADL's (hygiene, turning), assessments, pt. responses to
treatments
Scheduled meds, PRN meds, IV fluids/meds - ANSWERSWhat does the Medication Administration Record
(MAR) consist of?
-Discussing patients in public areas
-Leaving charts out
-Not logging off computers
-Copying forms0Social media
-Viewing charts for unassigned patients - ANSWERSConfidentiality/HIPAA Violations
-Treatment
-Payment
-Normal healthcare operations - ANSWERSWhat can protected healthcare information be released for?
-Public health reasons
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