NURS 122 Lecture WEEK 1 Verified Study Solutions With Latest Tests
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Course
NURS 122
Institution
NURS 122
NURS 122 Lecture WEEK 1 Verified Study Solutions With Latest Tests
discussion ANS an informal oral consideration of a subject by two or more healthcare personnel to identify a problem or establish strategies
report ANS oral, written, or computer-based communication intended to convey informat...
NURS 122 Lecture WEEK 1 Verified Study Solutions
With Latest Tests
discussion ANS an informal oral consideration of a subject by two or more healthcare personnel
to identify a problem or establish strategies
report ANS oral, written, or computer-based communication intended to convey information to
others
The process of making an entry on a patient record is called ANS recording, charting, or
documenting
clinical record ANS a formal, legal document that provides evidence of a patient's care
"The nurse has a duty to maintain confidentiality of all patient information" is said by who? ANS
The American Nurses Association (ANA) Code of Ethics
PHI is the abbreviation for ANS Protected Health Information
purposes of patient records include ANS communication, planning patient care, auditing health
agencies, research, education, reimbursement, legal documentation, healthcare analysis
the traditional patient record is called ANS a source-oriented record
narrative charting consists of what? ANS Written notes which include routine care, normal
findings, and patient problems
examples of diagnostic reports are ANS laboratory reports, x-ray reports, CT scan reports
examples of consultation reports are ANS physical therapy and respiratory therapy
, the abbreviation for POMR is ANS problem-oriented medical record
what is a POMR? ANS data is arranged according to the problems the patient has rather than
according to the source of the information
what are some advantages and disadvantages of a POMR? ANS advantages: they encourage
collaboration, and that the problem list in the front of the chart alerts caregivers to the patient's needs,
making it easier to track the status of each problem
disadvantages: not all caregivers can use the charting format effectively, constant vigilance is
required to maintain an up-to-date problem list which can be inefficient
what is a database? ANS all information known about the patient
SOAP is an acronym for ANS subjective, objective, assessment, and planning
subjective data ANS what the person says about himself or herself during history taking
objective data ANS information that is seen, heard, felt, or smelled by an observer; signs
assessment ANS interpretation or conclusions drawn about the subjective and objective data
interventions ANS actions taken to correct or manage a patient's problems
evaluation ANS patient responses to nursing interventions and medical treatments
revision ANS care plan modifications suggested by the evaluation
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