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12 Cards in this Set

  • Front
  • Back
Documentation is part of the ? phase of the nursing process
What are the 5 basic purposes to written patient records?
1. written communication; 2. permanent record for accountability; 3. legal record of care; 4. teaching; and 5. research and data collection
Are the only means institutions have to prove that they are providing care to meet the patient's needs and established standards
Accurate and legible records
Cost reimbursement rates by the government are based on _________?
DRGs-a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay
Institutions are reimbursed by insurance companies or government for?
DOCUMENTED patient care only!
Narrative charting includes:
basic pt need or problem data (subjective & objective), whether someone was contacted, care ad treatments provided (implementation), and the pt's response (evaluation)
Four common issues in malpractice caused by inadequate documentation are:
(1) not charting the correct time when events occured (2) failing to record verbal orders or failing to have them signed (3) charting actions in advance to save time (4) documenting incorrect data
What is the science of health?
Medical Asepsis
Clean technique
disease producing
Recommended room temperature for bathing should be:
68-74 degrees F
Factors that influence a patient's personal hygiene:
(1) Social practices (2) Body Image (3) Socioeconomic Status (4) Knowledge
(5) Personal preference
(6) Physical condition
(7) Cultural variables