NSG 1510 - Exam 1 Practice Questions and Correct Answers
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Course
NUR 1510
Institution
NUR 1510
Documentation the written or electronic legal record of all pertinent interactions with the patient-assessing, diagnosing, planning, implementing, and evaluating
Characteristics of effective communication - consistent with the professional&agency standards - complete - accurate - concise - factual...
NSG 1510 - Exam 1 Practice Questions
and Correct Answers
Documentation ✅the written or electronic legal record of all pertinent interactions with
the patient-assessing, diagnosing, planning, implementing, and evaluating
Characteristics of effective communication ✅- consistent with the professional&agency
standards
- complete
- accurate
- concise
- factual
- organized & timely
- legally responsible & prudent
- confidential
Elements of documentation ✅content, timing, format, accountability, confidentiality
Confidentiality ✅all information about patients written on paper, spoken aloud or saved
on computer.
Includes: name, address, ssn, illness, treatment, info about health conditions
Patients rights ✅factors of care that all patients can expect to receive
Includes: seeing their health record, updated record, list of disclosures, choosing how to
receive health info
Policy for receiving verbal orders ✅must be given directly by the physician or nurse
practitioner to a registered professional nurse or registered professional pharmacist
Record the orders in patient's medical record with the initials vo
Read back the order to verify accuracy
Date and note the time orders were issued
Record verbal order and name of the physician or np issuing the order, followed by
nurse's name and initials
Should be limited to urgent situations
Policy for physician or np review of verbal orders ✅review orders for accuracy
Sign orders with name, title and number
Date and note times order signed
Methods of documentation ✅ehr
Source-orientated notes
Problem-orientated notes
Pie charting
, Focus charting
Charting by exemption
Formats for nursing documentation ✅initial nursing assessment
Care plan; patient care summary
Critical collaborative pathways
Progress notes
Flow sheets and graphic records
Medication record
Acuity record
Discharge and transfer summary
Long-term care documentation
Medicare requirements for home health care ✅patient is homebound and still needs
skilled nursing care.
Rehabilitation potential is good (or patient is dying).
The patient's status is not stabilized.
The patient is making progress in expected outcomes of care.
Four components of rai ✅minimum data set
Triggers
Resident assessment protocols
Utilization guidelines
Benefits of rai ✅residents respond to individualized care.
Staff communication becomes more effective.
Resident and family involvement increases.
Documentation becomes clearer.
Reporting care or requesting action ✅-change of shift/handoff report
-isbarr
-telephone/telemedicine report
-transfer and discharge reports
-reports to family members or significant others
-incident/variance reports
Isbarr ✅introduction, situation, background, assessment, recommendation, read back
Shift change/hand-off report ✅basic information about patient
Current status of patients health status
Current orders
Abnormal occurrences that need continued
Any unfilled orders
Patient/family questions
Reports on transfers/dc
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