NSG 212 Exam 2 Questions With Complete Solutions
discussion - correct answerinformal oral consideration of a subject by 2 or more
healthcare personnel
report - correct answeroral, written, or computer-based communication intended to
convey info to others
record - correct answeralso called chart or client record. formal, legal document that
provides evidence of a client's care. can be written or computer based
documentation - correct answeris anything written or printed that is relied on as a record
or proof for authorized persons. must be accurate, comprehensive, and flexible enough
to retrieve critical data, maintain continuity of care, track client outcomes, and reflect
current standards of nursing practice
ensuring confidentiality of computer records - correct answerpersonal password that is
not to be shared. never leave a computer terminal unattended after logging on. do not
leave client info displayed on the monitor where others may see it. shred all unneeded
computer generated worksheets. use confidential trash cans. know the facilities policy
and procedure for correcting an entry error. follow agency procedures for documenting
sensitive material. IT must install a firewall to protect server from unauthorized access
usual policy for correcting an entry error - correct answera narrative entry in the medical
record stating that an error was made. when correcting or making a change to an entry,
the original entry should be viewable, the current date and time should be entered, the
person making the change should be identified, and the reason for making the change
should be noted
purposes of client records - correct answercommunication, planning client care, auditing
health care agencies, research, education, reimbursement, legal documentation, health
care analysis
communication - correct answerprevents fragmentation, repetition, and delays in care
labs drawn, patient bathed, medication ordered
planning client care - correct answernurses use baseline and ongoing data to evaluate
effectiveness of the care plan
wound care - documentation of status
auditing health agencies - correct answerReview client records for quality assurance
purposes
research - correct answertreatment plans for a number of clients with the same health
problems can yield information helpful in treating other clients
reimbursement - correct answerfrom the federal government, must contain correct
DRGs, the DRG classification system divides possible diagnoses into motor than 20
, NSG 212 Exam 2 Questions With Complete Solutions
major body systems and subdivides them into almost 500 groups for the purpose of
medicare reimbursement
legal documentation - correct answeradmissible in court in evidence unless client
objects because information client gives to primary care provider is confidential
health care analysis - correct answeridentify agency needs such as over utilized and
underutilized hospital services
in the court of law... - correct answer"care not documented is care not provided"
legal issues - correct answerindividualized, goal-directed record needs to describe
exactly what happened to client
4 common issues in malpractice caused by inadequate documentation are - correct
answernot charting the correct time when events occurred, failing to record verbal
orders or failing to have them signed, charting actions in advance to save time,
documenting incorrect data
source-oriented record - correct answertraditional client record. each discipline makes
notations in a separate section. information abut a particular problem distributed
throughout the record. narrative charting
different sheets/forms for different groups (RNs, MDs, PT, OT)
narrative charting (part of source oriented record slide) - correct answerwritten notes
that include routine care, normal findings, and client problems. often chronological
problem oriented medical record (POMR or POR) - correct answerdata arranged
according to patient problem, health team contributes to the problem list, plan of care,
and progress notes. encourages collaboration. easier to track status of problems.
vigilance required to maintain problems list. assessments and interventions must be
repeated when more than one problem exists
4 components - date base, problem list, plan of care, and progress notes
database - correct answerall information known about the client when the client first
enters the healthcare agency
problem list - correct answerlisted in order in which they are identified and other
resolved
plan of care - correct answermade with reference to active problems, generated by
individual who lists the problems
discussion - correct answerinformal oral consideration of a subject by 2 or more
healthcare personnel
report - correct answeroral, written, or computer-based communication intended to
convey info to others
record - correct answeralso called chart or client record. formal, legal document that
provides evidence of a client's care. can be written or computer based
documentation - correct answeris anything written or printed that is relied on as a record
or proof for authorized persons. must be accurate, comprehensive, and flexible enough
to retrieve critical data, maintain continuity of care, track client outcomes, and reflect
current standards of nursing practice
ensuring confidentiality of computer records - correct answerpersonal password that is
not to be shared. never leave a computer terminal unattended after logging on. do not
leave client info displayed on the monitor where others may see it. shred all unneeded
computer generated worksheets. use confidential trash cans. know the facilities policy
and procedure for correcting an entry error. follow agency procedures for documenting
sensitive material. IT must install a firewall to protect server from unauthorized access
usual policy for correcting an entry error - correct answera narrative entry in the medical
record stating that an error was made. when correcting or making a change to an entry,
the original entry should be viewable, the current date and time should be entered, the
person making the change should be identified, and the reason for making the change
should be noted
purposes of client records - correct answercommunication, planning client care, auditing
health care agencies, research, education, reimbursement, legal documentation, health
care analysis
communication - correct answerprevents fragmentation, repetition, and delays in care
labs drawn, patient bathed, medication ordered
planning client care - correct answernurses use baseline and ongoing data to evaluate
effectiveness of the care plan
wound care - documentation of status
auditing health agencies - correct answerReview client records for quality assurance
purposes
research - correct answertreatment plans for a number of clients with the same health
problems can yield information helpful in treating other clients
reimbursement - correct answerfrom the federal government, must contain correct
DRGs, the DRG classification system divides possible diagnoses into motor than 20
, NSG 212 Exam 2 Questions With Complete Solutions
major body systems and subdivides them into almost 500 groups for the purpose of
medicare reimbursement
legal documentation - correct answeradmissible in court in evidence unless client
objects because information client gives to primary care provider is confidential
health care analysis - correct answeridentify agency needs such as over utilized and
underutilized hospital services
in the court of law... - correct answer"care not documented is care not provided"
legal issues - correct answerindividualized, goal-directed record needs to describe
exactly what happened to client
4 common issues in malpractice caused by inadequate documentation are - correct
answernot charting the correct time when events occurred, failing to record verbal
orders or failing to have them signed, charting actions in advance to save time,
documenting incorrect data
source-oriented record - correct answertraditional client record. each discipline makes
notations in a separate section. information abut a particular problem distributed
throughout the record. narrative charting
different sheets/forms for different groups (RNs, MDs, PT, OT)
narrative charting (part of source oriented record slide) - correct answerwritten notes
that include routine care, normal findings, and client problems. often chronological
problem oriented medical record (POMR or POR) - correct answerdata arranged
according to patient problem, health team contributes to the problem list, plan of care,
and progress notes. encourages collaboration. easier to track status of problems.
vigilance required to maintain problems list. assessments and interventions must be
repeated when more than one problem exists
4 components - date base, problem list, plan of care, and progress notes
database - correct answerall information known about the client when the client first
enters the healthcare agency
problem list - correct answerlisted in order in which they are identified and other
resolved
plan of care - correct answermade with reference to active problems, generated by
individual who lists the problems
