Exam (elaborations)
NUR 304 ( LATEST 2024 / 2025 ) CHAPTER 16 | COMPLETE QUESTIONS & ANSWERS (SOLVED) 100% CORRECT
- Course
- Institution
NUR 304 ( LATEST 2024 / 2025 ) CHAPTER 16 | COMPLETE QUESTIONS & ANSWERS (SOLVED) 100% CORRECT
[Show more]
Content preview
NUR 304 Chapter 161. documentation
Answer
written, legal record of all pertinent interventions with the patient
- assessments, diagnoses, plans, interventions, and evaluations
2. patient record
Answer
a compilation of a patient's health information; the patient record is the only permanent legal
document that details the nurse's interactions with the patient
o The nurse's best defense if a patient or patient surrogate alleges nursing negligence
3. documentation
Answer
aims
complete, accurate, concise, cur- rent, factual, and organized data communicated in a timely and
confidential manner to facilitate care coordination and serve as a legal document
o Content
o Timing
Use the 24-hour cycle military clock for documenting times
o Format
o Accountability
o Confidentiality
4. confidential
Answer
All information about patients is considered private or
, whether written on paper, saved on a computer, or spoken aloud; this
,includes
o Names and all identifiers
o Reason the patient is sick
o Treatments received
o Information about past health conditions
5. HIPAA
Answer
rule that protects the privacy of individually indentifiable health information
6. security
Answer
rule that sets national standards for the security of electronic protected health information
7. breach notification
Answer
rule that requires covered entities and business associates to provide notification following a
breach of unsecured protected health information
8. patient safety
Answer
confidentiality provisions of the
- rule protects identifiable information being used to analyze patient safety events and
improves patient safety
9. false
T/F
Answer
according to HIPAA, patients have the right to revise the information in their health record
10. communication
Answer
a purpose of patient records; help health care professionals from different disciplines (who
, interact with the patient at different times) communicate with one another
o Fosters continuity of care
11. read back
Answer
the act in which the recipient reads back the verbal message as he or she heard and interpreted
it; the person giving the order then confirms that such recording and interpretation of the order
is correct
12. source-oriented
Answer
which type of record/documentation? a paper format in which each health care group keeps data
on its own separate form
o An advantage = each discipline can easily find and chart pertinent data
o Disadvantage = data are fragmented, making it difficult to track problems chrono- logically
with input from different groups of professionals
o Includes progress notes and narrative notes
13. problem-oriented
Answer
which type of record/documentation? a paper record used in some health agencies, organized
around a patient's problems rather than around sources of information; all health care
professionals record information on the same forms
o Advantage = the entire health care team works together in identifying a master list of patient
problems and contributes collaboratively to the plan of care
o SOAP format
14. intervention, evaluation, response
Answer
what does the IER in SOAPIER stand for?
15. PIE charting
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller gradexam. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $17.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
82191 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now