Soapier charting - Study guides, Class notes & Summaries

NUR155 EXAM (1)ONE STUDY GUIDE Exam One Study Guide With Complete Solutions Documenting and Reporting: Chart For everyone to see that is caring for patient, only look at charts of patients you need to know about. • can be formal or informal • oral written or computerized • chart is a legal record Legal considerations: • chart is legally protected • organization owns • patient has rights to chart • restricted access HIPPA: • Health insurance portability and accountabi...

Malpractice - Answer Failure by a health professional to meet LEGAL duty Elements of Malpractice - Answer Duty Breach Harm Proximate Cause Negligence - Answer failure to demonstrate proper care or knowledge Civil Litigation - Answer -lawsuit in a civil court -begins when the plaintiff contacts an attorney if malpractice is believed to be committed Nurse-Patient Relationship - Answer when the nurse assumes responsibility for the patient's care, resulting in legal liability if no...

Hondros NUR 150 final Questions and Answers (Verified Solutions) what are similar in hospital and long term care national patient safety goals? patient identification proper procedure for fecal impactation removal? Lube first two gloved fingers, insert into pt one at a time, in a scissor movement break down the stool and remove little by little. **Watch for fatigue, dispnea, heart palpitations What is the proper sequence to give medication/feeds vi NG tube? Check placement, pull residual, flus...

Auditors - answer-People appointed to examine patient charts and health records to assess quality of care Chart (healthcare record) - answer-Legal record that is used to meet the many demands of the health, accreditation, medical insurance and legal systems Charting - answer-The act of noting care and observations; documenting Charting by exception - answer-Focuses on deviation from the established norm or abnormal findings, highlights trends or changes Computer on wheels - answer-A ...

YOOST & CRAWFORD FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLABORATIVE PRACTICE, 2ND EDITION FOR MORE MATERIALS- Chapter 10: Documentation, Electronic Health Records, and Reporting MULTIPLE CHOICE 1. The nurse understands the need for accurate documentation due to which fact? a. Accurate documentation is needed for proper reimbursement. b. Accurate documentation must be electronically generated. c. Accurate documentation does not include e-mails or faxes. d. Accurate documentati...

functional ability CORRECT ANSWER a person's ability to perform the basic activities of daily living cognition CORRECT ANSWER the act of knowing and comprehending nutrition risk factors CORRECT ANSWER the poor and underserved, genetics, lifestyle patterns, personal choices, and environment aspiration CORRECT ANSWER withdrawal of fluid from a cavity or sac with an instrument using suction dysphagia CORRECT ANSWER difficulty swallowing elimination CORRECT ANSWER Act of removal of ...

Pre-interactive phase of a nurse-patient relationship - answer-Begins before the nurse's first contact w/the patient. The nurse's role is self-exploration and gathering data about the patient. Introductory or orientation phase of a nurse-patient relationship - answer-When the nurse & client first meet. The nurse seeks to find out why the client sought help. The tasks during this phase are to establish trust, understanding, acceptance, open communication and formulate a contract with the pat...

NURSING FUNDAMENTAL WEEK 10 FINAL EXAM Questions with Answers Submissions Question 1 After discussing the use of restraints with a client and family, a physician has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. Which of the following observations by the nurse indicates that the nursing assistant is using the restraints safely and correctly? Select all that apply. Response: The restraints are b...

YOOST & CRAWFORD FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLABORATIVE PRACTICE, 2ND EDITION FOR MORE MATERIALS- Chapter 10: Documentation, Electronic Health Records, and Reporting MULTIPLE CHOICE 1. The nurse understands the need for accurate documentation due to which fact? a. Accurate documentation is needed for proper reimbursement. b. Accurate documentation must be electronically generated. c. Accurate documentation does not include e-mails or faxes. d. Accurate documentati...

Pre-interactive phase of a nurse-patient relationship - Answer Begins before the nurse's first contact w/the patient. The nurse's role is self-exploration and gathering data about the patient. Introductory or orientation phase of a nurse-patient relationship - Answer When the nurse & client first meet. The nurse seeks to find out why the client sought help. The tasks during this phase are to establish trust, understanding, acceptance, open communication and formulate a contract with the pat...