Exam 4: Documentation and Informatics

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

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

Which is an acceptable format to use in documentation?

________________ provide a quick,easy reference for health care team members in assessing the patient's status.

Patients on the unit have their vital signs taken routinely at 0800,1200,1600,and 2000.At 1000,a patient complains of feeling "light-headed." The nurse takes the patient's vital signs and finds blood pressure to be lower than usual.Within 15 minutes,the patient says that he feels better.The nurse rechecks the blood pressure and finds that it is now back to normal.How should the nurse handle documentation for this episode?

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

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

Nursing documentation: (Select all that apply. )

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?

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

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

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

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?

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

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?

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

__________________ documentation should include your observations of patient behavior.

The patient is a 24-year-old man who is diagnosed with possible HIV infection while being treated for active pneumonia.He has stated that the nurse may share test result information with his significant other but nothing else at this time.With whom may the nurse communicate regarding this information?

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: