Show:
Reports
Purpose
Record-Keeping Forms
Methods
Progress Notes
100
TORB
What is telephone order read back
100
The nurse checks the clients chart to see how far the client ambulated on the previous shift
What is communication
100
The nurse checks the patient's chart to see if the patient was disoriented when they first arrived to the facility
What is admission nursing history form
100
Episode oriented with a separate record for each patient visit
What is paper record
100
Story-like format
What is narrative charting
200
Your client is being sent from the med-surg floor to ICU
What is transfer report
200
A medical record audit reviews a client's chart prior to payment for services
What is reimbursement
200
A quick and easy way to observe trends over time
What is flow sheet
200
Integrates all pertinent patient information into one computerized record
What is electronic health record
200
Assumes all standards are met unless otherwise documented
What is charting by exception
300
You receive a call from the lab stating your client has a creatinine of 3.2
What is telephone report
300
After caring for several clients with pneumonia, you are now able to identify common antibiotics used for treatment
What is education
300
Eliminates the need to constantly refer to the patient chart for basic patient care information
What is kardex
300
In Season 3 Episode 2, this is Episode 2
What is electronic medical record
300
Interdisciplinary care plans that include patient problems, key interventions, and expected outcomes within an established time frame
What are critical pathways
400
You explain to the oncoming nurse that the client's dressing change has not been completed
What is shift report
400
Statistical data from patient records indicate that TED hose are effective in preventing DVT's
What is research
400
Preprinted established guidelines of care for patient's with similar health problems.
What is standardized care plans
400
Includes database, problem list, initial care plan, discharge summary, and progress notes
What is problem-oriented medical record (POMR)
400
Includes data, action, and response
What is focus charting (DAR)
500
The healthcare provider calls and requests a CBC in the AM
What is a telephone order
500
The nurse manager reviews patient's charts to ensure that pain reassessments were done within one hour of pain med administration
What is quality process and performance improvement
500
Managerial and administrative staff gather information to make staffing decisions
What is acuity recording
500
Requires a plan of care for all patients on admission to acute, subacute, rehabilitation, and extended care agencies.
What is the Joint Commission
500
Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway time frame
What are variances