NUR 112 Exam 1 | QUESTIONS AND ANSWERS |
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Terms in this set (202)
Elements of Documentation - accessible
(Guidelines) - accurate
- relevant
- consistent
- auditable
- clear
- concise/ complete
- legible/readable
-thoughtful
- timely
- sequential
- reflective of the nursing process
- retrievable on a permanent basis in a nursing-
specific manner.
Who should document? Whoever is responsible for the nurses care should
chart but others can chart in as well. Everyone
should document!!!
,Why should you document without Poor documentation can be presumed as medical
error? negligence. "CYA".
Make sure you're documenting without error/ i.e.
Don't document the wrong BP. Can possibly affect
medication dosage.
Errors make nurses look less credible. Which can
affect credibility.
What is informatics? computer and software systems (may include pager
system any type of tech)
Should you skip lines if you're No!
charting?
, Approved abreviations A.C.- Before meals
b.i.d.- twice a day
c - with
D/C- discontinue or discharge
gtt, GTT- drops
IVPB- intravenous piggyback
mg-milligram
mcg- microgram
O.D.- right eye
O.S.- left eye
O.U.- both eyes
P- after
p.c.- after meals
PRN, p.r.n.- as needed
P.O., p.o.- by mouth
p.r., R- rectally
q.h.- every hour
q.i.d.- four times a day
QS- quantity sufficient
s- without
ss- one-half
t.i.d.- three times a day
What is HIPAA Health Insurance Portability and Accountability Act
LATEST UPDATE
Save
Terms in this set (202)
Elements of Documentation - accessible
(Guidelines) - accurate
- relevant
- consistent
- auditable
- clear
- concise/ complete
- legible/readable
-thoughtful
- timely
- sequential
- reflective of the nursing process
- retrievable on a permanent basis in a nursing-
specific manner.
Who should document? Whoever is responsible for the nurses care should
chart but others can chart in as well. Everyone
should document!!!
,Why should you document without Poor documentation can be presumed as medical
error? negligence. "CYA".
Make sure you're documenting without error/ i.e.
Don't document the wrong BP. Can possibly affect
medication dosage.
Errors make nurses look less credible. Which can
affect credibility.
What is informatics? computer and software systems (may include pager
system any type of tech)
Should you skip lines if you're No!
charting?
, Approved abreviations A.C.- Before meals
b.i.d.- twice a day
c - with
D/C- discontinue or discharge
gtt, GTT- drops
IVPB- intravenous piggyback
mg-milligram
mcg- microgram
O.D.- right eye
O.S.- left eye
O.U.- both eyes
P- after
p.c.- after meals
PRN, p.r.n.- as needed
P.O., p.o.- by mouth
p.r., R- rectally
q.h.- every hour
q.i.d.- four times a day
QS- quantity sufficient
s- without
ss- one-half
t.i.d.- three times a day
What is HIPAA Health Insurance Portability and Accountability Act
