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23 Cards in this Set
- Front
- Back
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The medical record is |
A legal record |
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Which method of documentation focuses on deviations from predefined norms |
Charting by exception |
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The original soap method is categorized in which method of documentation |
Problem-oriented medical record (POMR) charting |
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A disadvantage of charting by exception is that this method |
Requires development of detailed protocols and standars |
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An advantage of focus charting is that this method |
Shortens charting time by using flow sheets |
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Computerized provider order entry ( CPOE) allows for |
Automatic routing to the appropriate clinical areas for action |
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When documenting patient care |
Chart any new change in patient behaviour |
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What information is included in a care flow sheet |
Wound dressing changes |
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Documentation in a patient record Will |
Reveal evidence of patient care
Incorporated the nursing process |
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A(An) --------------- health record is a computerized comprehensive record of a client's history an care across all facilities |
Electronic |
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Verbal communication includes |
Spoken words |
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Active listening includes |
Focused energy |
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Which statement is true regarding the use of silence in communication |
Silence is a difficult technique to develop |
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Winch technique is used when a nurse ask a patient " tell my how your night was? " |
General lead |
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A Nurse uses the ISBAR R format for an end-of-shift report. IBAR R is an abbreviation for |
Introduction, situation, background, assessment, recommendation, and readback |
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__________ is the recognition and interpretation of sensory stimuli |
Perception |
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______________ objetives represent the desired changes or additions to current behaviour and attitudes |
Behavioral |
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One goal of healthy people 2020 is to |
Increase the life span |
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Method of documentation |
1 source-oriented 2 Problem-oriented 3 focus charting 4 charting by exception 5 computer-assisted 6Case management system |
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Problem oriented |
Focuses on the problems the PT experiences as results of being ill
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Charting by exception |
Which focuses on deviations from predefined norms using preset protocols and standards of care |
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Electronic health record (EHR) |
Is a computerized comprehensive record of a PT history and care across or all facilities |
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Discharge planning |
It is a process that begins at the time of admission |
