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Exam (elaborations)

NURS 6700 Exam 2 Questions And Correct Answers

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NURS 6700 Exam 2 Questions And Correct Answers ...

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  • September 22, 2024
  • 20
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • NURS 6700
  • NURS 6700
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Easton
NURS 6700 Exam 2 Questions And Correct
Answers 2024-2025


Access to patient records is limited to whom?

People involved in care of the patient ("Need to know")

What is the purpose of documentation?

professional responsibility of the RN

data to facilitate patient care/communication



legal record

data for clinical research/quality review

decision analysis

education

reimbursement

hospital accreditation

What is effective documentation?

factual, timely, accurate, professional, complete, confidential, organized

What information is documented by RN?

Assessments, plans, implementation/procedure, evaluation

When is information documented by RN?

upon admission, transfer or discharge

when a procedure if performed



when you've communicated something to the MD

,any change in patient status



frequency depending on the unit/hospital policy (hourly

patient rounds)

What are important methods in documentation?

confirming correct patient name before you make an entry



using black ink (if on paper)



using objective measurable terms



using only standard abbreviations and those accepted to the agency



timing and dating every entry



signing every entry



making sure there is a pt name or sticker on each page of chart

What are some unacceptable techniques in documentation?

charting for anyone other than yourself



signing anyone else's entry



using dittos, erasures, white out



scribbling over mistakes

What are some unaccepted abbrevations and symbols?

, U, IU, QD, QOD, trailing zero, lack of leading zero, MS, MSO4/MgSO4, <, >, @, cc

What is the major purpose of the hand-off report?

To maintain continuity of care

What is SOAPIER documentation?

• S - Subjective data

• O - Objective data

• A - Assessment

• P - Plan

• I - Intervention

• E - Evaluation

• R- Response

What is PIE charting?

• Problem

• Intervention

• Evaluation



problems numbered and charted/evaluated daily



problems drop from chart when they are resolved.

What is DAR charting?

Data



Action



Response



problem-oriented charting format

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