Chart (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 us...
UNITEK Ch. 3 Documentation Exam
Questions with Complete Solutions
Chart (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) - Answer-a 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 - Answer-The form on the patient's chart on which nurses record their
observations, care given, and the patient's responses
point-of-care - Answer-Bedside systems
computer on wheels - Answer-point of care systems housed on wheeled carts
nomenclature - Answer-A classified system of technical or scientific names and
terminology.
informatics - Answer-the sturdy of information processing
personal health record (PHR) - Answer-is an extension of the EHR that allows patients
to input their own information into an electronic database.
problem- oriented medical record - Answer-is organized according to the scientific
problem-solving system or method
database - Answer-accumulated data from the history, the physical examination, and
the diagnostic tests
SOAPE - Answer-subjective, objective, assessment, plan, evaluation. PART OF
FOCUS CHART
charting by exception (CBE) - Answer-Charting by exception. Only used in certain
facilities. Only charting things that really stand out, BY EXCEPTION
Acuity - Answer-Sharpness of health. High Acuity means more possibility of change of
condition. Low acuity means less susceptible..
nursing care plan - Answer-Plan that outlines the proposed nursing care based on the
nursing assessment and nursing diagnoses to provide continuity of care
Incident report - Answer-Nurse should only give objective data. Nurse should not admit
liability or give unnecessary details
Charting, recording, or documenting - Answer-is the process of adding information to
the chart.
Documenting - Answer-involves recording the interventions carried out to meet the
patient's needs
5 Basic purposes for documentation - Answer-1) documented communication
2) permanent record for accountability
3) legal record of care
4) teaching
5) research and data collection
Auditors - Answer-peer review
Quality assurance, assessment, and improvement
Diagnosis-related groups
Nurses notes - Answer-where nurses record observations, care given, and patient
responses institutions reimbursed by
Peer review - Answer-an appraisal by professional coworker of equal status.
SBAR (situation, background, assessment, recommendation) - Answer-is 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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