Character attack uttered orally in the presence of others.
What is slander.
100
Collections of information about a person's health and care provided by practitioners and the facility. Used for permanent health history, sharing info between healthcare workers, legal evidence, reimbursement, accreditation and quality assurance of the facility/workers.
What is medical record.
100
Records organized according to the type of practitioner/health care worker documenting the information
What is source - oriented records.
100
A part of verbal communication that is very important with elderly clients.
What is active listening.
100
The role the nurse takes when performing health-related activities that a sick person cannot perform independently.
What is nurse as caregiver.
200
written account of an unusual, potentially injurious event involving a client, employee, or visitor. Not placed in the medical record. Must contain complete description of event. Who what when & where
What is an incident report.
200
What laws are behind the reasoning for placing x ray boxes in private areas, cover sheets on faxes, not discussing other clients in or near a client's room, and limiting access to client's charts to specific personnel.
What is HIPAA laws.
200
Records organized according to the client's health problems containing the database, problem list, plan of care and progress notes. Also where would one chart the response of the client to the plan of care.
What is problem oriented record & in the progress notes.
200
Using words and gestures to accomplish a particular objective/goal.
What is therapeutic communication.
200
Nursing role in which one provides information and teaching pertinent to client's needs.
What is nurse as educator.
300
When a client is forewarned of a potential safety hazard and chooses to ignore the warning, the court may hold the client responsible for own injury.
What is Assumption of risk
300
This information is required on every page of a client's medical record to maintain legal status and every entry should have what at the end.
What is client's name and date of birth & signed name and title of health care worker.
300
Style of documentation generally used in source-oriented records, involves writing information about the client and care in chronological order.
What is narrative charting
300
abbreviation for "before meals"
What is a.c.
300
Nursing role in which one who works with others to achieve a common goal.
What is nurse as collaborator.
400
Type of litigation in which one person asserts that a physical, emotional, or financial injury was a consequence of another person's actions or failure to act.
What is a tort.
400
When an error in a medical record occurs, the best way to correct the error is how?
What is a single line through the error portion.
400
Type of charting that documents only abnormal assessment findings.
What is charting by exception.
400
abbreviation for "complaining of"
What is C/O
400
Nursing role in which one assigns a task to someone with appropriate legal ability to perform it.
What is nurse as delegator.
500
Ethical decision making based on final outcomes. Using this theory the decision is based on what is best for the most people.
What is teleologic theory.
500
Failure to leave people and their property alone. Including but not limited to photography of a client without consent, revealing a client's name in a public report, and allowing unauthorized personnel to access/observe clients care or records.
What is invasion of privacy.
500
Charting style more likely to be used in a problem oriented record that uses four essential components- subjective & objective data, analysis of data, and plan of care.
What is SOAP charting.
500
WNL is the abbreviation for ?
What is "within normal limits."
500
laws that provide legal immunity to passersby who provide emergency first aid to victims of accidents.