Questions and Answers
What is the purpose of documentation?
Tracking the nurses on each shift
Improving the facility's care quality
Facilitating communication among team members
Sharing data with insurance companies
Allowing nurses to summarize physician findings
Creating legal report of care delivery
Providing consistent care from shift to shift - Correct answer Improving the facility's care quality
Facilitating communication among team members
Creating legal report of care delivery
Providing consistent care from shift to shift
What are some common charting formats?
Narrative
SOAPIE
Summarize, Organize, Assessment, Plan, Implement, Evaluate
Medication Administration Record
Exception
Focus Charting
Emergency
Problem—Intervention—Evaluation - Correct answer Narrative
SOAPIE
Exception
, Focus Charting
Problem—Intervention—Evaluation
What are some advantages of electronic records?
More secure
Neater and easier to read
Can transfer information to multiple departments
Can be used by several people at once
Less repetition
More accurate
Less "down time"
Saves time for nurses - Correct answer More secure
Neater and easier to read
Can transfer information to multiple departments
Can be used by several people at once
Less repetition
More accurate
Saves time for nurses
Which abbreviations are on The Joint Commission's "do not use" list?
oz for ounce
U or u
IU
MS for magnesium sulfate
Q.D. for daily
Q.O.D.