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17 True/False questions

  1. SBARsituation, background, assessment, recommendation

          

  2. SOAPsubjective, obejective, assessment, plan

          

  3. admission nursing history formsprovide baseline data to compare with changes in the clients condition.

          

  4. narrative reportsstory telling

          

  5. source recordseparate section for each discipline

          

  6. critical pathwaysdetermine the hours of care and staff required for a given group of clients.

          

  7. discharge summary formsseparate section for each discipline

          

  8. charting by exceptionstory telling

          

  9. Focus Chartinginvolves the use of data, action, and response (DAR)

          

  10. acuity recordsdetermine the hours of care and staff required for a given group of clients.

          

  11. PIEproblem, intervention, and evaulation

          

  12. Problem-oriented medical recordseparate section for each discipline

          

  13. flow sheetsdata entry of assessment such as vital signs, hygiene measures, ambulation, restraint checks

          

  14. SOAPIEsubjective, obejective, assessment, plan

          

  15. kardexproblem, intervention, and evaulation

          

  16. standardized care planstory telling

          

  17. case managementdata entry of assessment such as vital signs, hygiene measures, ambulation, restraint checks