WEEK 1 (PNUR 124) PART 2 WITH 100%
CORRECT ANSWERS
the ___ is federal legislation that protects personal information, including health information - ANSWER-Personal Information
Protection and Electronic Documents Act (PIPEDA)
a patient's ___, or chart, is a confidential, permanent legal document of information relevant to a patient's health care - ANSWER-
record
___ are oral, written, or audiotaped exchanges of information between caregivers - ANSWER-reports
quality documentation has six important characteristics: it is... - ANSWER-factual, accurate, complete, current, and organized, and
it complies with standards set by regulatory bodies
a ___ record contains descriptive, objective information about what a nurse sees, hears, feels, and smells - ANSWER-factual
the use of ___ establishes accuracy and helps the nurse determine if a patient's condition has changed in a positive or negative
way - ANSWER-exact measurements
the information within a recorded entry or a report must be ___, containing appropriate and essential information - ANSWER-
complete
___ should occur during or as soon as possible after the incident or intervention - ANSWER-documentation
what is SOAP? - ANSWER-subjective, objective, assessment, plan
what is PIE? - ANSWER-problem, intervention, evaluation
wha is focus charting DAR? - ANSWER-data, action, responsew
, ____ is the use of a storylike format to document information - ANSWER-narrative documentation
the ____ is a system of organizing documentation to place the primary focus on patients' individual problems - ANSWER-problem-
oriented medical record (POMR)
in POMR, data is organized by... - ANSWER-problem or diagnosis
the POMR has the following major sections... - ANSWER-database, problem list, care plan, and progress notes
what is the database of the problem-oriented medical record (POMR)? - ANSWER-the database section contains all available
assessment information pertaining to the patient
next, the ___ includes a patient's physiological, psychological, social, cultural, spiritual, developmental, and environmental needs
[problem-oriented medical record (POMR)] - ANSWER-problem list
health care providers write progress notes in one of several formats or structured notes within a POMR including what types? -
ANSWER-1. subjective-objective-assessment plan (SOAP)
2. PIE
3. DAR
in some institutions, an "I" and an "E" are added (i.e., SOAPIE), for... - ANSWER-Intervention and Evaluation
the PIE format differs from the SOAP method in that PIE... - ANSWER-originated in nursing practice, whereas SOAP charting
originated from medical records
the PIE format simplifies documentation by... - ANSWER-unifying the care plan and progress notes
CORRECT ANSWERS
the ___ is federal legislation that protects personal information, including health information - ANSWER-Personal Information
Protection and Electronic Documents Act (PIPEDA)
a patient's ___, or chart, is a confidential, permanent legal document of information relevant to a patient's health care - ANSWER-
record
___ are oral, written, or audiotaped exchanges of information between caregivers - ANSWER-reports
quality documentation has six important characteristics: it is... - ANSWER-factual, accurate, complete, current, and organized, and
it complies with standards set by regulatory bodies
a ___ record contains descriptive, objective information about what a nurse sees, hears, feels, and smells - ANSWER-factual
the use of ___ establishes accuracy and helps the nurse determine if a patient's condition has changed in a positive or negative
way - ANSWER-exact measurements
the information within a recorded entry or a report must be ___, containing appropriate and essential information - ANSWER-
complete
___ should occur during or as soon as possible after the incident or intervention - ANSWER-documentation
what is SOAP? - ANSWER-subjective, objective, assessment, plan
what is PIE? - ANSWER-problem, intervention, evaluation
wha is focus charting DAR? - ANSWER-data, action, responsew
, ____ is the use of a storylike format to document information - ANSWER-narrative documentation
the ____ is a system of organizing documentation to place the primary focus on patients' individual problems - ANSWER-problem-
oriented medical record (POMR)
in POMR, data is organized by... - ANSWER-problem or diagnosis
the POMR has the following major sections... - ANSWER-database, problem list, care plan, and progress notes
what is the database of the problem-oriented medical record (POMR)? - ANSWER-the database section contains all available
assessment information pertaining to the patient
next, the ___ includes a patient's physiological, psychological, social, cultural, spiritual, developmental, and environmental needs
[problem-oriented medical record (POMR)] - ANSWER-problem list
health care providers write progress notes in one of several formats or structured notes within a POMR including what types? -
ANSWER-1. subjective-objective-assessment plan (SOAP)
2. PIE
3. DAR
in some institutions, an "I" and an "E" are added (i.e., SOAPIE), for... - ANSWER-Intervention and Evaluation
the PIE format differs from the SOAP method in that PIE... - ANSWER-originated in nursing practice, whereas SOAP charting
originated from medical records
the PIE format simplifies documentation by... - ANSWER-unifying the care plan and progress notes
