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?

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

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

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

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)?

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

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

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

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

To limit liability,nursing documentation must clearly indicate that the nurse provided individualized,goal-directed nursing care to a patient based on the _____________________.

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

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?

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?

__________________ documentation should include your observations of patient behavior.

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:

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

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?

Which is an acceptable format to use in documentation?

Nursing documentation must have which of the following characteristics?

Nursing documentation: