Exam 4: Documentation and Informatics

The patient has been transferred to the nursing home from the acute care hospital.A report was called from the hospital and was received by the RN in charge of the nursing home unit.Upon arrival, which approach is used to assess the patient?

Nursing documentation must have which of the following characteristics? (Select all that apply.)

Nursing documentation: (Select all that apply.)

The nurse manager is attempting to determine the staffing needs of the unit.One tool that she may use to determine the level of care needed would be:

Which of the following is the best example of objective charting?

The patient was in bed with all side rails up.During the night, the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails.After meeting the patient's needs and assessing that the patient was not harmed, what step should the nurse take (if any)?

Which is a primary difference between home care and hospital care?

The abbreviation for every day (___) is no longer used.

Which of the following is the best example of accurate documentation?

The patient has been in the hospital for a hip replacement.According to his critical pathway, he should have his Foley catheter discontinued on the fourth day after surgery.Instead, the patient has it removed on the third day and is voiding normally with no problems.This would be a sign of:

___________________ provide a format for documenting a patient's health status and progress.

When making written entries in the patient's medical record, describe the nursing care provided and the ____________.

A preprinted guideline used to care for patients with similar health problems is known as the:

Standardized care plans are effective ways to plan care for the patient.To be most effective, however, the SCP must be _________________.

What is the goal of information management? (Select all that apply.)

A patient's private health information is legally protected by the ________________.

The patient is ready to go home from the hospital.What does the nurse provide to the patient and his family before he leaves the facility?

Which is a delivery model that coordinates and links health care services to patients and families?

The nursing assistant tells the RN that when the patient's vital signs were taken, the patient complained that she was in a lot of pain.The nursing assistant then tells the nurse that she charted the patient's complaint when she charted the vital signs.What instruction does the nurse need to provide to the nursing assistant?

Multidisciplinary care plans that include key interventions and expected outcomes within an established time frame are known as _______________.