Fundamentals Test 1 - Delta College Questions With
Complete Solutions
Proper charting covers all areas of patients needs and concerns:
physical, emotional, psychological, social, spiritual
Current regulations requre _____ ______ by officially appointed
auditors
Chart audits
Auditors check to see whether...
All care was charted as given and whether responses to specific
care plan items and treatments are noted
Institutions have ________ and ______ _______ systems
Medical and peer review
Institutions also have specific procedures to provide for
__________ __________, _________, and ___________, which
is an audit in health care that evaluates services provided and the
results achieved compared with accepted standards.
Quality assurance, assessment, and improvement
What are the only means institutions have to prove they are
providing care to meet patients needs and established standards?
Accurate and legible record
________ _________ ________ is a system that classified
patients by age, diagnosis, surgical procedure, and other info
with 25 major diagnostic categories and hundreds of different
,subcategories to predict the use of hospital resources, including
length of stay, resulting in a fixed payment
Diagnosis-related groups
ISBARR stands for:
Introduction, Situation, Background, Assessment,
Recommendation, Read back
SBAR is recognized by:
The joint commission as one method of meeting National
Patient Safety Goals
Accurate __________ is one of the best defenses in the event of
legal claims associated with nursing care
Documentation
Some examples of inappropriate documentation includes:
Not charting correct time events occurred, failing to record
verbal orders, charting nursing care in advance, documenting
incorrect data
Basic rules for documentation....
Should have pt name, identification number, date of birth, time
Avoid generalized empty statements
Be objective
Chart after care - not before
Chart as soon as possible
Chart facts
Go line by line, do not indent
, Use direct quotes when appropriate
Avoid rushing
What should you do if there is a written error on your chart?
Draw a single line through error
Avoid ___________ to complete charting. Be sure info is
accurate.
Rushing
Do not leave blank spaces in nursing notes. Instead chart.....
Consecutively, line by line. If space is left, draw line
horizontally and sign at the end
The __________ ________ ________ _________ is organized
according to the scientific problem-solving system or method.
Problem-oriented medical record (POMR)
_________ is the briefer adaptation of the charting format for
the POMR
SOAPE
________ ________ uses the nursing process and the patients
needs rather than medical diagnoses and problems
Focus charting
____ is the acronym for 4 different aspects of charting using the
focus format.
DARE
DARE stands for:
Complete Solutions
Proper charting covers all areas of patients needs and concerns:
physical, emotional, psychological, social, spiritual
Current regulations requre _____ ______ by officially appointed
auditors
Chart audits
Auditors check to see whether...
All care was charted as given and whether responses to specific
care plan items and treatments are noted
Institutions have ________ and ______ _______ systems
Medical and peer review
Institutions also have specific procedures to provide for
__________ __________, _________, and ___________, which
is an audit in health care that evaluates services provided and the
results achieved compared with accepted standards.
Quality assurance, assessment, and improvement
What are the only means institutions have to prove they are
providing care to meet patients needs and established standards?
Accurate and legible record
________ _________ ________ is a system that classified
patients by age, diagnosis, surgical procedure, and other info
with 25 major diagnostic categories and hundreds of different
,subcategories to predict the use of hospital resources, including
length of stay, resulting in a fixed payment
Diagnosis-related groups
ISBARR stands for:
Introduction, Situation, Background, Assessment,
Recommendation, Read back
SBAR is recognized by:
The joint commission as one method of meeting National
Patient Safety Goals
Accurate __________ is one of the best defenses in the event of
legal claims associated with nursing care
Documentation
Some examples of inappropriate documentation includes:
Not charting correct time events occurred, failing to record
verbal orders, charting nursing care in advance, documenting
incorrect data
Basic rules for documentation....
Should have pt name, identification number, date of birth, time
Avoid generalized empty statements
Be objective
Chart after care - not before
Chart as soon as possible
Chart facts
Go line by line, do not indent
, Use direct quotes when appropriate
Avoid rushing
What should you do if there is a written error on your chart?
Draw a single line through error
Avoid ___________ to complete charting. Be sure info is
accurate.
Rushing
Do not leave blank spaces in nursing notes. Instead chart.....
Consecutively, line by line. If space is left, draw line
horizontally and sign at the end
The __________ ________ ________ _________ is organized
according to the scientific problem-solving system or method.
Problem-oriented medical record (POMR)
_________ is the briefer adaptation of the charting format for
the POMR
SOAPE
________ ________ uses the nursing process and the patients
needs rather than medical diagnoses and problems
Focus charting
____ is the acronym for 4 different aspects of charting using the
focus format.
DARE
DARE stands for:
