NUFT 204 EXAM Prep Questions with 100% Correct Verified Solutions Change -of-shift Report - Answer communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiot aped Charting by Exception (CBE) - Answer shorthand method for documenting patient data that is based on well -defined standards of practice; only exceptions to these standards are documented in narrative notes Collaborative pathway - Answer Confer - Answer to consult with someone to exchange ideas or to seek information, advice, or instructions Consultation - Answer process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution Critical/collaborative Pathway - Answer case management plan that is detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and t he sequence and timing of those interventions Discharge Summary - Answer description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including re ferrals Documentation - Answer written, legal record of all pertinent interventions with the patient ---assessments, diagnoses, plans, interventions, and evaluations Electronic Health Record (EHR)/Electronic Medical Record (EMR) - Answer computer -
based re cord of data that can be distributed among many caregivers in a standardized format Flow Sheet - Answer graphic record of abbreviated aspects of patient's condition (e.g., vital signs, routine aspects of care) Focus Charting - Answer a documentation syst em that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R ) format Hand -off - Answer A nurses report to another nurse or healthcare provider about a patient status or progress Health information exchange (HIE) - Answer an electronic system that allows physicians, nurses, pharmacists, and other health care provi ders, and patients to appropriately access and securely share the patient's vital medical information Incident/variance Report - Answer a report of any event that is not consistent with the routine operation of the health care agency that results in or has the potential to result in harm to a patient, employee, or visitor ISBARR communication - Answer a p rocess for effective hand -off communication among health care professionals about a patient's condition, standing for Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read back. Meaningful use - Answer the use of certified ele ctronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare and Medicaid Narrative notes - Answer progress notes written by nurses in a source -oriented record Nursing informatics - Answer A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Outcome and Assessment Information Set (OASIS) - Answer assessment instrument representing core item s of comprehensive assessment for adult non maternity home healthcare patients that forms the basis for measuring Occurrence/variance charting - Answer When a patient fails to meet an expected outcome or a planned intervention is not implemented, includin g the unexpected event, the cause of the event, actions taken in response of the event and discharge planning when appropriate. Usually used for variances that affect quality, cost, or length of stay Patient record - Answer a compilation of a patient's he alth information; the patient record is the only permanent legal document that details the nurse's interactions with the patient Personal health record (PHR) - Answer information sheets that contain the individual's medical history, including diagnoses, s ymptoms, and medications PIE Charting - Answer documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P), intervention (I), evaluation(E) format, and evaluated each shift
