documentation 1
documentation 2
yes, more documentation
even more documentation!
WORD MEANING
100
Institutions are reimbursed only for care that is documented because of this.
What is managed care?
100
"Without the documentation, you did not do it"
What my attorney will tell me if I did not document care?
100
Peer Review
What is the process used to appraise the practice of an individual nurse?
100
Data, action, response, education-charting system.
What is the DARE system that uses assessment for the data portion?
100
DERMATOLOGY and lithotripsy
What is THE STUDY OF SKIN? what is crushing or removing a calculus or stone?
200
When the nurse charts only additional treatments done, changes in patient condition, and new concerns -
What is charting by exception?
200
the nurse has a clinical reason to look at the chart.
What is the only reason the nurse has a requirement to read the record.
200
problem oriented format is used in this documentation format.
What is SOAPE documentation?
200
leave blank space, include mean retaliatory comments, include speculation, draw pictures and doodle--
What is NOT included when you document in a patient's chart?
200
endocarditis carcinoma
What is the inflammation of the inner layer of the heart? What is a cancerous tumor?
300
the form used when facility or national standards of expected care are not met.
What is the incident form?
300
I chart when I return to work, using the term "late entry" alongside the date and time you are actually charting.
What is the plan when my facility uses paper charting and forgot to chart something?
300
the institution is the legal owner.
Who is the legal owner of the patient's medical record?
300
incorrectly documenting the time of an event, charting in advance treatments or events, documenting and incorrect date?
What are some things that can lead to a malpractice suit?
300
hepatomegaly polyuria
What is enlargement of the liver? What is excreting a large amount of urine?
400
the form of integrated care plans made with all disciplines for a projected length of stay for the patients.
What is critical pathway
400
the basis for focus charting.
How is the nursing diagnosis used in focus charting?
400
logging off, not sharing your password, closing computer, not discussing any patient with anybody outside of the required needs of the workplace.
What are methods to maintain privacy and to ensure no one alters the information you enter in the computer?
400
security, expensive, learning new terminology.
What are some problems with EMR?
400
rhinoplasty hemolysis
What is the surgical repair of the nose? what is the breakdown of blood cells?
500
"really, really, I did the care, I just forgot to chart that night, I was so busy"
What a nurse might say if there is no documentation in the file for care she/he provided?
500
to evaluate care results against accepted standards.
What is the purpose of QA or quality assurance?
500
Subjective information, objective information, assessment plan, evaluation.
What is does the acronym SOAPE stand for?
500
3 purposes of the EMR or written record.
What are teaching, legal record of care, and for research and data collection?
500
arthralgia leukopenia
what is pain in the joint? what is a decrease in the number of WBC's?
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