Exam (elaborations)
UNITEK Ch. 3 Documentation Questions and Answers 2024
UNITEK Ch. 3 Documentation
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UNITEK Ch. 3 DocumentationChart (health care record) - answer Legal record that is used to meet many demands of
the health accreditation, medical insurance, and legal systems.
charting, recording, or documenting - answer The process of adding information to the
chart
Electronic health record (EHR) – answer EHRs are used in various settings, including
hospitals, long-term care settings, health care provider's offices, clinics, and home care
agencies.
Peer review - answer An appraisal by professional coworkers of equal status
quality assurance, assessment, and improvement - answer An audit in health care that
evaluates services provided and the results achieved compared with accepted
standards
diagnosis-related groups (DRGs) - answera system that classifies patients by age,
diagnosis, surgical procedure, and other information with hundreds of different
categories to predict the use of hospital resources, including length of stay, resulting in
a fixed payment amount
nursing notes - answerThe form on the patient's chart on which nurses record their
observations, care given, and the patient's responses
point-of-care - answerBedside systems
computer on wheels - answerpoint of care systems housed on wheeled carts
nomenclature - answerA classified system of technical or scientific names and
terminology.
informatics - answerthe sturdy of information processing
personal health record (PHR) - answeris an extension of the EHR that allows patients to
input their own information into an electronic database.
problem- oriented medical record - answeris organized according to the scientific
problem-solving system or method
, database - answeraccumulated data from the history, the physical examination, and the
diagnostic tests
SOPIER - answersubjective, objective, assessment, plan, intervention, evaluation,
revision. FOCUS CHART
SOAPE - answersubjective, objective, assessment, plan, evaluation. PART OF FOCUS
CHART
charting by exception (CBE) - answerCharting by exception. Only used in certain
facilities. Only charting things that really stand out, BY EXCEPTION
Acuity - answerSharpness of health. High Acuity means more possibility of change of
condition. Low acuity means less susceptible..
nursing care plan - answerPlan that outlines the proposed nursing care based on the
nursing assessment and nursing diagnoses to provide continuity of care
Incident report - answerNurse should only give objective data. Nurse should not admit
liability or give unnecessary details
Charting, recording, or documenting - answeris the process of adding information to the
chart.
Documenting - answerinvolves recording the interventions carried out to meet the
patient's needs
5 Basic purposes for documentation - answer1) documented communication
2) permanent record for accountability
3) legal record of care
4) teaching
5) research and data collection
Auditors - answerpeer review
Quality assurance, assessment, and improvement
Diagnosis-related groups
Nurses notes - answerwhere nurses record observations, care given, and patient
responses institutions reimbursed by
Peer review - answeran appraisal by professional coworker of equal status.
SBAR (situation, background, assessment, recommendation) - answeris a method of
communication among health care workers and a part of documentation. Known as a
safety measure in preventing errors from poor communication during"hand off" or
"handover" interactions. (When your changing shifts)
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