NUR 155 Exam 1: Documentation (Ch. 15)
Admission Nursing Assessment (ANA) - CORRECT ANSWER-Completed when
the client is admitted to the nursing unit. Includes: Demographics, Baseline data,
and Critical elements.
Assessment - CORRECT ANSWER-An interpretation or inclusion drawn about
the subjective and objective data.
Charting by Exception (CBE) - CORRECT ANSWER-Charting where only
abnormal or significant findings or exceptions are recorded.
Data, Action, Response - CORRECT ANSWER-Progress notes are organized
into DAR. What does DAR stand for?
Documenting Nursing Activities (DNA) - CORRECT ANSWER-Record should
describe the client's ongoing status and reflect the full range of the nursing
process.
Electronic Health Record (EHR) - CORRECT ANSWER-Used to manage large
volumes of information required in contemporary health care. Used to store the
client's database, new data, create and revise care plans and document client's
progress.
Evaluation - CORRECT ANSWER-The client's responses to nursing
interventions and medical treatment.
Flow Sheets - CORRECT ANSWER-Allows nurses to record nursing data quickly
and concisely.
Includes: Graphic record, Intake and output, Medication administration record,
and Skin assessment record.
Focus Charting - CORRECT ANSWER-Charting that is intended to make the
client and clients concerns and strengths the focus of care.
Graphic Record - CORRECT ANSWER-This record indicates body temperature,
pulse, blood pressure, and weight.
Admission Nursing Assessment (ANA) - CORRECT ANSWER-Completed when
the client is admitted to the nursing unit. Includes: Demographics, Baseline data,
and Critical elements.
Assessment - CORRECT ANSWER-An interpretation or inclusion drawn about
the subjective and objective data.
Charting by Exception (CBE) - CORRECT ANSWER-Charting where only
abnormal or significant findings or exceptions are recorded.
Data, Action, Response - CORRECT ANSWER-Progress notes are organized
into DAR. What does DAR stand for?
Documenting Nursing Activities (DNA) - CORRECT ANSWER-Record should
describe the client's ongoing status and reflect the full range of the nursing
process.
Electronic Health Record (EHR) - CORRECT ANSWER-Used to manage large
volumes of information required in contemporary health care. Used to store the
client's database, new data, create and revise care plans and document client's
progress.
Evaluation - CORRECT ANSWER-The client's responses to nursing
interventions and medical treatment.
Flow Sheets - CORRECT ANSWER-Allows nurses to record nursing data quickly
and concisely.
Includes: Graphic record, Intake and output, Medication administration record,
and Skin assessment record.
Focus Charting - CORRECT ANSWER-Charting that is intended to make the
client and clients concerns and strengths the focus of care.
Graphic Record - CORRECT ANSWER-This record indicates body temperature,
pulse, blood pressure, and weight.
