3/21/25, 7:38 NU-136 Flashcards |
AM
NU-136 EXAM QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS VERIFIED
Terms in this set (45)
if it isn't recorded, it didn't happen, to identify actual and potential health problems,
Purpose of documentation
plan appropriate care, evaluate the pt's responses to tx,
Facility own record
Of pt wants record they need to go through medical records
Consent
The medical record (chart) Pre op
Timeout
Transfer
healthcare group keeps data on its own separate forms. different sections designed
for nurses, physicians, laboratory etc
Source oriented charting main disadvantage is data is fragmented making it difficult to track problems and
time consuming
a documentation system that replaces the problem list with a focus column that
incorporates many aspects of a patient and patient care; the focus may be a
Focus charting patient strength or a problem or need; the narrative portion of focus charting uses
the data (D), action (A), response (R) format
Focus charting disadvantage Not enough information on pt focuses on problem
shorthand method for documenting patient data that is based on well-defined
Charting by exception standards of practice; only exceptions to these standards are documented in
narrative notes disadvantage forget to document
Computer assisted charting Where data are input to the computer
Case management charting Makes sure patient leaves the facility on time with no complications
Be specific and definite in using words or phrases that convey the meaning you wish
Accuracy of documentation expressed
Words that have ambiguous meanings and slang should not be used in charting
-Single line through incorrect documentation followed by initials
1/
5
, 3/21/25, 7:38 NU-136 Flashcards |
AM
- Do not erase, bold, or use whiteout
-do not skip lines
- Darw a line through blank spaces
errors in documentation
***use agency policy
Asian Americans prefer 2 1/2-4ft and avoid eye contact
language barrier Get interpreter
Obtaining feedback Ask pt to repeat,demonstrate and write
therepeutic communication Open ended questions
Block to communication Advice,judge-mental, false reassurance,
Get their attention first
Communication with hearing impaired Talk closer to ear
Use shirt sentences
Use clock
Communication with visually impaired Announce yourself
Do not rearrange furniture
Eye level
Be honest
Communicating with children Have child hold equipment
Be kind
Let them
Communication adolescente
talk Build
trust
2/
5
AM
NU-136 EXAM QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS VERIFIED
Terms in this set (45)
if it isn't recorded, it didn't happen, to identify actual and potential health problems,
Purpose of documentation
plan appropriate care, evaluate the pt's responses to tx,
Facility own record
Of pt wants record they need to go through medical records
Consent
The medical record (chart) Pre op
Timeout
Transfer
healthcare group keeps data on its own separate forms. different sections designed
for nurses, physicians, laboratory etc
Source oriented charting main disadvantage is data is fragmented making it difficult to track problems and
time consuming
a documentation system that replaces the problem list with a focus column that
incorporates many aspects of a patient and patient care; the focus may be a
Focus charting patient strength or a problem or need; the narrative portion of focus charting uses
the data (D), action (A), response (R) format
Focus charting disadvantage Not enough information on pt focuses on problem
shorthand method for documenting patient data that is based on well-defined
Charting by exception standards of practice; only exceptions to these standards are documented in
narrative notes disadvantage forget to document
Computer assisted charting Where data are input to the computer
Case management charting Makes sure patient leaves the facility on time with no complications
Be specific and definite in using words or phrases that convey the meaning you wish
Accuracy of documentation expressed
Words that have ambiguous meanings and slang should not be used in charting
-Single line through incorrect documentation followed by initials
1/
5
, 3/21/25, 7:38 NU-136 Flashcards |
AM
- Do not erase, bold, or use whiteout
-do not skip lines
- Darw a line through blank spaces
errors in documentation
***use agency policy
Asian Americans prefer 2 1/2-4ft and avoid eye contact
language barrier Get interpreter
Obtaining feedback Ask pt to repeat,demonstrate and write
therepeutic communication Open ended questions
Block to communication Advice,judge-mental, false reassurance,
Get their attention first
Communication with hearing impaired Talk closer to ear
Use shirt sentences
Use clock
Communication with visually impaired Announce yourself
Do not rearrange furniture
Eye level
Be honest
Communicating with children Have child hold equipment
Be kind
Let them
Communication adolescente
talk Build
trust
2/
5
