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NURS 6700 Exam 2 Questions And Correct Answers
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NURS 6700 Exam 2 Questions And CorrectAnswers 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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