Types of documentation
In SOAPE Charting, what does "P" stand for?
P- Plan
(Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision)
PO
By mouth
Form used to document any event not consistent with the routine operation of a health care unit or the routine care of a patient, is sometimes necessary in response to an unplanned occurrence within a health care facility.
Incident Report
True or False:
The patient chart or health record is a legal document; when necessary and appropriate, it is used in court proceedings.
True
Who is the legal owner of the patient’s medical record?
The institution
In SBAR charting, what does "B" stand for?
B- Background
Situation, Background, Assessment, Recommendation
NPO
Nothing by mouth
System is used by some facilities to consolidate patient orders and care needs in a centralized, concise way.
Kardex or Rand system
The record facilitates accurate ________ and continuity of care among all members of the health care team.
Communication
What does the "A" in DARE system of charting stand for?
Action-
data, action, response, education (DARE)
The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation?
A. SOAP
B. BLOCK
C. CBE
D. FOCUS
C. CBE ( Charting By Exception)
q
Every
Is written documentation of instructions given to the patient and so that the patient can refer to those instructions after being discharged.
Discharge summary
A system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount.
A payment system of diagnosis-related groups (DRGs)- A Cost reimbursement system.
What is a method of communication among health care workers and a part of documentation?
SBAR (situation, background, assessment, and recommendation)
What does the nurse use as a basis for documentation in focus charting?
A. Problem list
B. Nursing orders
C. Patient problems
D. Evaluation
C. Patient problems-
In focus charting, instead of using the problem list, modified patient problems are used as an index for nursing documentation.
ac
Before meals
Outlines the proposed nursing care based on the nursing assessment and the identified patient problems to provide continuity of care. Is developed to meet the nursing care needs of a patient.
Nursing care plan
What is the process used to appraise the practice of an individual nurse known as?
A. Quality Assurance
B. Incident reporting
C. OBRA
D. Peer review
D. Peer review
Peer review is an in-house department study that may appraise the nursing practice of individual nurses.
True or False?
Inappropriate documentation may lead to nursing malpractice.
True
What is the documentation format that uses the acronym SOAPE?
A. Problem- Oriented
B. Focused
C. Traditional
D. Crisis
A. Problem-Oriented
The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems. (Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision)
c/o
Complains of
Uses a score that rates each patient by severity of illness. With documentation and analysis of nursing interventions, an overall level of acuity for each patient is determined. Helps determine nurse patient ratios.
Acuity Charting
What is the purpose of QA (quality assurance)?
A. To screen employment applications
B. To evaluate care results against accepted standards
C. To conduct in-services for “quality documentation”
D. To report deviation from standards to the state health department
B. To evaluate care results against accepted standards-
QA is an in-house department that evaluates care services and results against accepted standards.
What is 2pm in Military time?
1400