Documentation lvn
The process of adding info - answerCharting, recording, or documenting
5 basic purposes for accurate and complete or records are - answerDocumented
communication, pernenant record of accountability, legal record if care, teaching, and
reasearch and data collection
Proper charting covers which areas of pt needs and concerns - answerPhysical,
emotional, psychological, social, and spiritual
Nursing Process - answerAssessment, Diagnosis, Planning, Implementation, Evaluation
To limit nursing liability documentation must - answerClearly indicate that individualized
goal oriented nursing care was provided to pt based on the nursing assessment
All documentation should have correct - answerPt name, if #, dob,date, and time if
appropriate
Use only approved - answerAbbreviations and medical terms
When documenting never leave - answerSpace or empty lines
When do you chart the care that was provided - answerAfter pt care
Problem oriented medical record pomr - answerOrganized according to the specific
problem solving system or method
Principle sections of problem oriented medical record - answerDatabase, problem list,
care plan, and progress notes
SOAPIER - answerSubjective, objective, assessment, plan, intervention, evaluation,
and revision
Soape - answerSubjective, objective, assessment, plan, and evaluation
Dare - answerData, action, response and evaluation, education & pt teaching
Charting by exception cbe - answerNurse charts complete physical assessment,
observation, vital signs, over rite and rate, and other pertinent data at beginning of each
shift
Pie - answerProblem, Intervention, Evaluation
The process of adding info - answerCharting, recording, or documenting
5 basic purposes for accurate and complete or records are - answerDocumented
communication, pernenant record of accountability, legal record if care, teaching, and
reasearch and data collection
Proper charting covers which areas of pt needs and concerns - answerPhysical,
emotional, psychological, social, and spiritual
Nursing Process - answerAssessment, Diagnosis, Planning, Implementation, Evaluation
To limit nursing liability documentation must - answerClearly indicate that individualized
goal oriented nursing care was provided to pt based on the nursing assessment
All documentation should have correct - answerPt name, if #, dob,date, and time if
appropriate
Use only approved - answerAbbreviations and medical terms
When documenting never leave - answerSpace or empty lines
When do you chart the care that was provided - answerAfter pt care
Problem oriented medical record pomr - answerOrganized according to the specific
problem solving system or method
Principle sections of problem oriented medical record - answerDatabase, problem list,
care plan, and progress notes
SOAPIER - answerSubjective, objective, assessment, plan, intervention, evaluation,
and revision
Soape - answerSubjective, objective, assessment, plan, and evaluation
Dare - answerData, action, response and evaluation, education & pt teaching
Charting by exception cbe - answerNurse charts complete physical assessment,
observation, vital signs, over rite and rate, and other pertinent data at beginning of each
shift
Pie - answerProblem, Intervention, Evaluation
