NSC 232 Final EKU Questions and Answers(A+ Solution guide)
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Course
NSC 232 EKU
Institution
NSC 232 EKU
Documentation Guidelines: Accountability - ️️-sign first name, last name, title to
each entry
-do not use dittos, erasers, correcting fluids, etc.
-identify each page record
-record is permanent
Documentation Guidelines: Content - ️️-complete, accurate, concise, factual
-reflecting nu...
NSC 232 Final EKU
Documentation Guidelines: Accountability - ✔️✔️-sign first name, last name, title to
each entry
-do not use dittos, erasers, correcting fluids, etc.
-identify each page record
-record is permanent
Documentation Guidelines: Content - ✔️✔️-complete, accurate, concise, factual
-reflecting nursing process
-record observations, not interpretation
-terminology
-sequencing
-include safety precautions
-medical visits, consultations
-document nursing response to questionable medical orders
-avoid use of stereotypes or derogatory terms
Effective Communication - ✔️✔️-essential to the coordination and continuity of care
-enables personnel to support and compliment one another's services
-avoid duplications and omissions of care
Purposes of Documentation - ✔️✔️-communication
-planning client care
-quality assurance
-research
-education
-reimbursement
-legal documentation
Documentation - ✔️✔️-is written or typed
-a legal record of all pertinent interactions with a patient
Nursing Process - ✔️✔️-assessing
-diagnosing
-planning
-implementing
-evaluating
Documentation Guidelines: Timing - ✔️✔️-timely
-include date and time
-24 hour clock
-do not document before carrying out
,Documentation Guidelines: Format - ✔️✔️-correct chart
-appropriate form
-write legibly
-use standard terminology
-date and time each entry
-chart interventions chronologically
-use consecutive lines, do not skip lines
Documentation Guidelines: Confidentiality - ✔️✔️-patient moral and legal rights
(HIPAA)
Types of Nursing Documentation - ✔️✔️-admission notes
-change of shift notes
-assessment notes
-interval or progress notes
-transfer and discharge notes
-client teaching notes
Documentation Systems - ✔️✔️-narrative charting
-focus charting
-charting by exception (CBE)
-problem oriented medical record (POMR)
-PIE
-flow sheets
-graphic records
-clinical pathways (care maps)
POMR - ✔️✔️subjective, objective, assessment, plan
Vital Signs - ✔️✔️-temperature
-pulse
-respiratory
-blood pressure
-(pain is referred to as the 5th vital sign)
When to Assess Vital Signs - ✔️✔️-upon admission
-change in clients health status
-client reports symptoms such as pain, feeling hot, or faint
-pre and post surgery/invasive procedure
-pre and post medication administration that could affect the cardiovascular system
-pre and post nursing intervention that could affect vital signs
Bradypnea - ✔️✔️abnormally slow respiratory rate
-usually less than 10 respirations per minute
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