Fundamentals in Nursing II (NURB 240)
Exam 1 Study Guide DRAFT
When is a narrative note useful? - ANSWER-Narrative charting is used to tell a story
and has several standardized formats, including SOAP. Narrative notes are useful in
any situation where something unusual/unexpected happens or when you need to
communicate with a provider.
What are violations of confidentiality/HIPAA? - ANSWER-Leaking any of the following:
-Names (full or last name and initial)
-All geographical identifiers smaller than a state
-Dates (other than year) directly related to an individual
-Phone numbers
-Fax numbers
-Email address
-SSN
-MRN
-Health insurance beneficiary numbers
-Account numbers
-Certificate/license numbers
-Vehicle identifiers (including VIN and license plate)
-Device identifiers and serial numbers (such as for an implant or pacemaker)
-Web URL
-IP addresses
-Biometric identifiers, including finger, retinal, and voice prints
-Full face photographic images or similar
-Any other unique identifying number or characteristic
How might one avoid or correct violations of confidentiality/HIPAA? - ANSWER-DO:
-Log off of EHRs when you walk away (even for a second)
-Ensure conversations are private
-Dispose of papers securely
-Be careful when faxing/emailing/printing info
DON'T
-Leave paper charts lying open or unsecured
-Include irrelevant information or gossip in charting or report
-Access charts for patients you are not caring for or do not have a legitimate work-
related reason to access information on
, -Share information with other healthcare providers unless it is needed to provide good,
safe care for the patient
What is SOAP charting? - ANSWER-Subjective data --> what the patient says
Objective data --> what you observe, such as VS, lab results, and physical assessment
findings
Assessment --> interpret the subjective and objective data and state the problem or
note client progress on the problem (may be in the form of a nursing diagnosis)
-Plan --> plan of care to address the problem
What are prohibited abbreviations, and what are the corrections? - ANSWER-Format:
(Prohibited abbreviation ) = (Correct term)
-U = unit
-IU = International Unit
-Q.D. (QD, qd, q.d.), Q.O.D. (QOD), qod, q.o.d.) = daily, every other day
-Trailing zero (X.0 mg) = never write a zero by itself after decimal point (X mg)
-Lack of leading zero (.X mg) = always use a zero before a decimal point (0.X mg)
-MS, MSO4, MgSO4 = morphine or magnesium
-µg = mcg or microgram
-cc = ml for milliliters
-AS, AD, AU, OS, OD, OU = left ear, right ear, both ears, left eye, right eye, both eyes
-Ambivalent duration (such as bid x 10d) = "doses" or "days"
-SQ, SC = write "Sub-Q" or "subcutaneously"
What are some errors in handoff reporting, and how might they be corrected? -
ANSWER-
What is SBAR? - ANSWER-SBAR (used during handoff reports or when communicating
with MD/physician/NP about concerns):
-Situation --> What is happening at the current time? What is the important problem?
(provide a brief description of patient variables, demographics, diagnosis, and location)
-Background --> What are the circumstances that lead to this situation? What subjective
and objective data do you have that is important for the receiver to know? (provide
history as it is related to patient's current health)
-Assessment --> What do you think is happening? (state interpretation of assessment
data)
-Recommendation/Request --> What do you think needs to be done? (state what you
need for patient in terms of treatment or assistance)
What is included in a correct labeling of a specimen collection? - ANSWER--Requisition
-Patient's name and ID # (MRN)
-Patient's DOB
Exam 1 Study Guide DRAFT
When is a narrative note useful? - ANSWER-Narrative charting is used to tell a story
and has several standardized formats, including SOAP. Narrative notes are useful in
any situation where something unusual/unexpected happens or when you need to
communicate with a provider.
What are violations of confidentiality/HIPAA? - ANSWER-Leaking any of the following:
-Names (full or last name and initial)
-All geographical identifiers smaller than a state
-Dates (other than year) directly related to an individual
-Phone numbers
-Fax numbers
-Email address
-SSN
-MRN
-Health insurance beneficiary numbers
-Account numbers
-Certificate/license numbers
-Vehicle identifiers (including VIN and license plate)
-Device identifiers and serial numbers (such as for an implant or pacemaker)
-Web URL
-IP addresses
-Biometric identifiers, including finger, retinal, and voice prints
-Full face photographic images or similar
-Any other unique identifying number or characteristic
How might one avoid or correct violations of confidentiality/HIPAA? - ANSWER-DO:
-Log off of EHRs when you walk away (even for a second)
-Ensure conversations are private
-Dispose of papers securely
-Be careful when faxing/emailing/printing info
DON'T
-Leave paper charts lying open or unsecured
-Include irrelevant information or gossip in charting or report
-Access charts for patients you are not caring for or do not have a legitimate work-
related reason to access information on
, -Share information with other healthcare providers unless it is needed to provide good,
safe care for the patient
What is SOAP charting? - ANSWER-Subjective data --> what the patient says
Objective data --> what you observe, such as VS, lab results, and physical assessment
findings
Assessment --> interpret the subjective and objective data and state the problem or
note client progress on the problem (may be in the form of a nursing diagnosis)
-Plan --> plan of care to address the problem
What are prohibited abbreviations, and what are the corrections? - ANSWER-Format:
(Prohibited abbreviation ) = (Correct term)
-U = unit
-IU = International Unit
-Q.D. (QD, qd, q.d.), Q.O.D. (QOD), qod, q.o.d.) = daily, every other day
-Trailing zero (X.0 mg) = never write a zero by itself after decimal point (X mg)
-Lack of leading zero (.X mg) = always use a zero before a decimal point (0.X mg)
-MS, MSO4, MgSO4 = morphine or magnesium
-µg = mcg or microgram
-cc = ml for milliliters
-AS, AD, AU, OS, OD, OU = left ear, right ear, both ears, left eye, right eye, both eyes
-Ambivalent duration (such as bid x 10d) = "doses" or "days"
-SQ, SC = write "Sub-Q" or "subcutaneously"
What are some errors in handoff reporting, and how might they be corrected? -
ANSWER-
What is SBAR? - ANSWER-SBAR (used during handoff reports or when communicating
with MD/physician/NP about concerns):
-Situation --> What is happening at the current time? What is the important problem?
(provide a brief description of patient variables, demographics, diagnosis, and location)
-Background --> What are the circumstances that lead to this situation? What subjective
and objective data do you have that is important for the receiver to know? (provide
history as it is related to patient's current health)
-Assessment --> What do you think is happening? (state interpretation of assessment
data)
-Recommendation/Request --> What do you think needs to be done? (state what you
need for patient in terms of treatment or assistance)
What is included in a correct labeling of a specimen collection? - ANSWER--Requisition
-Patient's name and ID # (MRN)
-Patient's DOB
