NUR215 EXAM QUESTIONS AND ANSWERS A+ GRADED
source-oriented system
disciplines document in separate sections of the chart, scattered data
problem-oriented system
Organized around client problems, four components: database, problem list, plan of
care, and progress notes, promotes greater collaboration
charting by exception
Only significant findings are documented, uses flowsheets, reduces documentation
time, but can lead to omission of information and errors in care. Assumes all standards
have been met unless separate entry is made.
Electronic Health Record Systems
Advantages: enhances communication across disciplines, improves access to
information, time saving, improving quality of care.
Disadvantages: expensive, downtime, change issues, lack of integration
Narrative documentation
"Story" of care in chronological format.
PIE Documentation
Problem, Interventions, Evaluation. Used only in problem-oriented charting.
SOAPIE Charting
Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision
Focus Charting
Data, Action, Response
Electronic Entry
streamlines process, moves documentation to bedside, decision-making processes are
immediate.
Kardex
Care summary given to client
Nursing Admission Assessment
record of baseline data to monitor change, includes questions and SAMPLE info.
ISBAR
Identify, Situation, Background, Assessment, Recommendation
Incident Report
accident report used to improve health care quality.
Date, time, order given, how it was given, providers name, signature.
Telephone Orders
Kyphosis
excessive outward curvature of the spine, causing hunching of the back. Thoracic
Curve.
Scoliosis
abnormal lateral curvature of the spine
Lordosis
Abnormal anterior curvature of the spine. Accentuated Lumbar Curve.
Sprain
wrench or twist of a ligament of a joint
source-oriented system
disciplines document in separate sections of the chart, scattered data
problem-oriented system
Organized around client problems, four components: database, problem list, plan of
care, and progress notes, promotes greater collaboration
charting by exception
Only significant findings are documented, uses flowsheets, reduces documentation
time, but can lead to omission of information and errors in care. Assumes all standards
have been met unless separate entry is made.
Electronic Health Record Systems
Advantages: enhances communication across disciplines, improves access to
information, time saving, improving quality of care.
Disadvantages: expensive, downtime, change issues, lack of integration
Narrative documentation
"Story" of care in chronological format.
PIE Documentation
Problem, Interventions, Evaluation. Used only in problem-oriented charting.
SOAPIE Charting
Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision
Focus Charting
Data, Action, Response
Electronic Entry
streamlines process, moves documentation to bedside, decision-making processes are
immediate.
Kardex
Care summary given to client
Nursing Admission Assessment
record of baseline data to monitor change, includes questions and SAMPLE info.
ISBAR
Identify, Situation, Background, Assessment, Recommendation
Incident Report
accident report used to improve health care quality.
Date, time, order given, how it was given, providers name, signature.
Telephone Orders
Kyphosis
excessive outward curvature of the spine, causing hunching of the back. Thoracic
Curve.
Scoliosis
abnormal lateral curvature of the spine
Lordosis
Abnormal anterior curvature of the spine. Accentuated Lumbar Curve.
Sprain
wrench or twist of a ligament of a joint
