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37 True/False questions

  1. diagnosis-related group (DRG)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.

          

  2. CBE1)Situation (state problem and chief complaints) 2)Background (admitting dx, current meds, allergies, lab results, important info.) 3)Assessment 4)Recommendation

          

  3. critical pathwaymultidisciplinary care plans that include client problems, key interventions, and expected outcomes within an established time frame.

          

  4. problem-oriented medical record (POMR)client's chart has a separate section for each discipline to record data. (ex. nursing, medicine, social work, respiratory therapy)

          

  5. governmental agenciesquality control and justification for reimbursement from Medicare, Medicaid or private insurance.

          

  6. standardized care plansway to determine the hours of care and staff required for a give group of clients.

          

  7. case managementmodel of delivering care that incorporates a multidisciplinary approach to documenting client care.

          

  8. varianceunexpected outcomes, unmet goals, and interventions not specified within the critical pathway time frame.

          

  9. The Joint Commissionprofessional caregiver providing formal advice to another caregiver.

          

  10. SOAP format1)Subjective data 2)Objective data (measured and observed) 3)Assessment (diagnosis based on data) 4)Plan (what caregiver plans to do)

          

  11. SOAPIE1)Situation (state problem and chief complaints) 2)Background (admitting dx, current meds, allergies, lab results, important info.) 3)Assessment 4)Recommendation

          

  12. flow sheetforms that allow nurses to quickly and easily enter assessment data about the client. (ex. vital signs, hygeine, ambulation, meals, weight, etc.)

          

  13. DRG'shave become the basis for establishing reimbursement for client care.

          

  14. record (chart)confidential, permanent legal documentation of information relevant to a client's health care.

          

  15. PIE format1)Subjective data 2)Objective data (measured and observed) 3)Assessment (diagnosis based on data) 4)Plan (what caregiver plans to do)

          

  16. source recordclient's chart has a separate section for each discipline to record data. (ex. nursing, medicine, social work, respiratory therapy)

          

  17. 1)SOAP 2)PIE 3)Focus Charting (DAR)3 Formats for Progress Notes method

          

  18. Kardexcomputerized system that provides basic summative information in the form of client care summary that is printed for each client each shift for easy reference.

          

  19. reportoral, written or audiotaped exchanges of information between caregivers. (change of shift, telephone, transfer, incident)

          

  20. Omnibus Budget Reconciliation Act (1987)includes Medicare and Medicaid legislation for long-term documentation.

          

  21. confidentialityprofessional caregiver providing formal advice to another caregiver.

          

  22. DAR (Focus charting)confidential, permanent legal documentation of information relevant to a client's health care.

          

  23. documentationquality control and justification for reimbursement from Medicare, Medicaid or private insurance.

          

  24. source recordway to determine the hours of care and staff required for a give group of clients.

          

  25. federal/state regulations, state statues, standards of care, accreditation agenciesimproves 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.

          

  26. referralarrangement for services by another care provider.

          

  27. documentationanything written or printed relating to the client, that you rely on as record or proof for authorized persons.

          

  28. proper documentationquality control and justification for reimbursement from Medicare, Medicaid or private insurance.

          

  29. charting by exception (CBE)focuses on documenting deviations from the established norm or abnormal findings.

          

  30. HIPAAlegislation that protects client privacy for health information. (requires disclosure or requests regarding health information.)

          

  31. consultationquality control and justification for reimbursement from Medicare, Medicaid or private insurance.

          

  32. accreditationquality control and justification for reimbursement from Medicare, Medicaid or private insurance.

          

  33. communication, legal documentation, financial billing, education, research, auditing - monitoringincludes Medicare and Medicaid legislation for long-term documentation.

          

  34. narrative documentationtraditional method for recording that uses storylike format to document information specific to client conditions and nursing care.

          

  35. acuity recordsway to determine the hours of care and staff required for a give group of clients.

          

  36. American Nurse Associationspecify guidelines for documentation. (The Joint Commission)

          

  37. SBAR1)Situation (state problem and chief complaints) 2)Background (admitting dx, current meds, allergies, lab results, important info.) 3)Assessment 4)Recommendation