Soapier charting - Study guides, Class notes & Summaries

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...

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 documentation is only accepted...

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...

lOMoARcPSD| FIN 6406 The Nursing process of Critical Thinking And Decision making After completing the initial head-to-toe shift assessment, the nurse determines that no changes are needed in the client’s plan of care. Which evaluation process supports the nurse’s decision? Answer s: a. Reviewing the effectiveness of previously initiated nursing interventions b. Recognizing that the client may be discharged from the hospital dur...

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...

S = Situation -what is going on with the client/ patient (Chest pain, nausea, etc...) B = Background- client’s/ patient's presenting complaint, relevant past medical history and brief summary of background A = Assessment - Vital signs, any outside normal parameters, your clinical impression, severity of client/ patient and clinical concerns R = Recommendation- suggestions of what action is to be take, how urgent and when action needs to be taken. R= Review - what has been the effect of...

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 documentation is only accepted in court if written by hand. ANS: A Accurate documentation is necessary for hospitals to be r...

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...

YOOST & CRAWFORD FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLABORATIVE PRACTICE, 2ND EDITIONFOR 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 documentation i...

YOOST & CRAWFORD FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLABORATIVE PRACTICE, 2ND EDITIONFOR 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 documentation i...