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35 Matching questions

  1. source record
  2. narrative documentation
  3. confidentiality
  4. DRG's
  5. HIPAA
  6. charting by exception (CBE)
  7. Omnibus Budget Reconciliation Act (1987)
  8. diagnosis-related group (DRG)
  9. accreditation
  10. American Nurse Association
  11. case management
  12. SBAR
  13. PIE format
  14. record (chart)
  15. SOAPIE
  16. acuity records
  17. 1)SOAP 2)PIE 3)Focus Charting (DAR)
  18. DAR (Focus charting)
  19. report
  20. communication, legal documentation, financial billing, education, research, auditing - monitoring
  21. critical pathway
  22. The Joint Commission
  23. documentation
  24. variance
  25. governmental agencies
  26. flow sheet
  27. consultation
  28. proper documentation
  29. problem-oriented medical record (POMR)
  30. CBE
  31. SOAP format
  32. Kardex
  33. referral
  34. standardized care plans
  35. federal/state regulations, state statues, standards of care, accreditation agencies
  1. a professional caregiver providing formal advice to another caregiver.
  2. b clients are grouped together by diagnosis, surgical procedures, complications, preexisting conditions, age and everything done for a client must be documented in the medical record so that the health care institution can recover its costs.
  3. c improves standards of health and the availability of health care, to foster high standards for nursing, and to promote the professional development and welfare of nurses.
  4. d quality control and justification for reimbursement from Medicare, Medicaid or private insurance.
  5. e best defense of legal claims associated with nursing care.
  6. f instrumental in determining the standards and policies for documentation in long-term health care.
  7. g nurses are legally and ethically obligated to keep information about clients confidential.
  8. h 1)Situation (state problem and chief complaints) 2)Background (admitting dx, current meds, allergies, lab results, important info.) 3)Assessment 4)Recommendation
  9. i 1)Data (both subjective and objective) 2)Action of nursing intervention 3)Response of the client (evaluation of effectiveness)
    -incorporates all aspects of nursing process, highlights client concerns and can be integrated in any clinical setting.
  10. j confidential, permanent legal documentation of information relevant to a client's health care.
  11. k oral, written or audiotaped exchanges of information between caregivers. (change of shift, telephone, transfer, incident)
  12. l computerized system that provides basic summative information in the form of client care summary that is printed for each client each shift for easy reference.
  13. m advantage- caregivers can easily locate each section to document entries. disadvantage- client's problems are distributed across the record.
  14. n 3 Formats for Progress Notes method
  15. o pre-printed established guidelines that are used to care for clients with similar health problems, that are based on the institution's standard of nursing practice.
  16. p includes Medicare and Medicaid legislation for long-term documentation.
  17. q method of documentation that emphasizes the client's problems. Data is organized by problem or diagnosis. Includes: 1)Database 2)Problem list 3)Nursing care plan 4)Progress notes
  18. r 1)Subjective data 2)Objective data 3)Assessment 4)Plan 5)Intervention 6)Evaluation
  19. s 1)Subjective data 2)Objective data (measured and observed) 3)Assessment (diagnosis based on data) 4)Plan (what caregiver plans to do)
  20. t have become the basis for establishing reimbursement for client care.
  21. u way to determine the hours of care and staff required for a give group of clients.
  22. v focuses on documenting deviations from the established norm or abnormal findings.
  23. w model of delivering care that incorporates a multidisciplinary approach to documenting client care.
  24. x main purposes of records for patients.
  25. y requires documentation within the context of the nursing process. requires that accredited hospitals have written nursing policies and procedures and quality improvement programs. requires multidisciplinary plan. (expand..)
  26. z advantage- reduces documentation time and highlights trends or changes. disadvantage- system can pose legal risks if nurses do not document.
  27. aa legislation that protects client privacy for health information. (requires disclosure or requests regarding health information.)
  28. ab arrangement for services by another care provider.
  29. ac unexpected outcomes, unmet goals, and interventions not specified within the critical pathway time frame.
  30. ad specify guidelines for documentation. (The Joint Commission)
  31. ae 1)Problem 2)Intervention 3)Evaluation
    originates from nursing diagnosis, rather than medical diagnosis. Notes are numbered according to client's problems. Continuing problems documented daily.
  32. af traditional method for recording that uses storylike format to document information specific to client conditions and nursing care.
  33. ag forms that allow nurses to quickly and easily enter assessment data about the client. (ex. vital signs, hygeine, ambulation, meals, weight, etc.)
  34. ah all together set nursing documentation standards.
  35. ai multidisciplinary care plans that include client problems, key interventions, and expected outcomes within an established time frame.