Soapie charting - Study guides, Class notes & Summaries

What is the purpose of documentation? - Answer-Facilitating communication among team members. Creating a legal report of care delivery. Providing consistent care from shift to shift. Improving the facility's care quality. What are some common charting formats? - Answer-- SOAPIE - Focus charting - Narrative - Problem / intervention / evaluation - Exception What are some advantages of electronic records? - Answer-- Saves time for nurses - less repetition - more accurate - can be used ...

Patients have the right to... - see and copy their health record - update their health record - get a list of disclosures - request a restriction on certain uses or disclosures - choose how to receive information Similar to a credit card that has a magnetic strip that contains vital emergency healthcare information or a link to healthcare info using pin number health care smart card Patient care record created when facilities under different ownership share their data; accessible to designated...

What aspects of the therapeutic nurse Client relationship is addressed in the article "lend an ear"? - Answer-Trust and respect What is one way a nurse violates the nurse client relationship? - Answer-When we don't listen. What is the goal behind listening according to Broeder-morin and land? - Answer-Gain empathetic understanding How does a nurse show they are listening? - Answer-Eye contact, arms uncrossed, facial expression, touch, warmth What are the client consequences of not...

1. What aspects of the therapeutic nurse Client relationship is addressed in the article "lend an ear"?: Ans- Trust and respect 2. What is one way a nurse violates the nurse client relationship?: Ans- When we don't listen. 3. What is the goal behind listening according to Broeder-morin and land?: - Ans- Gain empathetic understanding 4. How does a nurse show they are listening?: uncrossed, facial expression, touch, warmth Eye contact, arms 5. What are the client consequences o...

NUFT 204 Exam Questions and Answers Latest Updated 2024/2025 (100% Solved) Current health or history of current illness - HPI (history of present illness 4.Past health 5.Family history 6.Review of systems - Head to toe 7.Functional assessment or ADLs " Examples of Biographical data in health hstory - ANSWER "Name •Address and phone number •Age and birth date •Birthplace •Sex •Marital status •Race •Ethnic origin •Occupation—usual and present •Source of informa...

methods of documentation - Answer -Source-oriented records -Problem-oriented medical records -PIE charting (problem, intervention, evaluation) -Focus charting -Charting by exception; provides quick access to abnormal findings -Case management model -Computerized documentation/Electronic health records (EHRs) -SBAR/ISBAR source oriented records - Answer each health care group keeps data on its own separate form -progress/narrative notes -observation of patients, patient complain...

1. What aspects of the therapeutic nurse Client relationship is addressed in the article "lend an ear"?: Ans- Trust and respect 2. What is one way a nurse violates the nurse client relationship?: Ans- When we don't listen. 3. What is the goal behind listening according to Broeder-morin and land?: - Ans- Gain empathetic understanding 4. How does a nurse show they are listening?: uncrossed, facial expression, touch, warmth Eye contact, arms 5. What are the client consequences o...

CPOE reduces transcription errors - A group of nurses are discussing the advantages of using computerized provider order entry (CPOE). Which statements indicate that the nurses understand the major advantage of using CPOE? the patient had two cups of soup and it was tolerated well - The primary healthcare provider orders a clear liquids diet for a patient with gastritis. On the first day, the patient consumes soup and tolerates it well. How does the nurse document this finding? enter only ...

1. What aspects of the therapeutic nurse Client relationship is addressed in the article "lend an ear"?: Ans- Trust and respect 2. What is one way a nurse violates the nurse client relationship?: Ans- When we don't listen. 3. What is the goal behind listening according to Broeder-morin and land?: - Ans- Gain empathetic understanding 4. How does a nurse show they are listening?: uncrossed, facial expression, touch, warmth Eye contact, arms 5. What are the client consequences o...