Nurs- B260 Fundamentals Exam with perfect answers 2024

Medical Record correct answers Purpose: -Facilitate interdisciplinary communication, provide a record of care, allow for auditing, monitoring, and evaluation of care provided. Also serve as sources of research data and learning resources -Used for communication, legal documentation, reimbursement for health care services, auditing and monitoring (to see if standards of care were met) Guidlines for Quality Documentation correct answers -Factual -Accurate -Complete -Current -Organized Narrative correct answers Method of documentation: -used to record patient assesment and nursing care provided. Uses story like format to document the information SOAP correct answers Method of documentation: subjective, objective, assesment, plan PIE correct answers Method of documentation: problem, intervention, evaluation Focus Charting (DAR) correct answers Method of documentation: data, action, response Problem Oriented Medical Record correct answers Method of documentation: places primary focus on patients individual problems- data bases, problem list, care plan, progress notes Charting by Exception correct answers shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes Within defined limits correct answers WDL Within normal limits correct answers WNL Document every call correct answers You should ________ made to a provider Patient's 5 Rights correct answers Right: -patient