chapter 4

batch charting

waiting until end of shift or until all patients have been assessed to document finding from all of them

flow sheet

efficient and standardized from that assembles the collected information in a way that permits easy comparison among assessment data to detect trends or a sudden change in status

audit

review of a health care facility by an agency or outside group to determine whether that facility is providing and documenting certain standards of care

handoff

transfer of care fro a patient from one health provider to another

charting by exception

use of predetermined standards and norms to record only significant assessment data

C

A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse? A. it maximizes compliance with standards of documentation B. it disables the graphing of trends in vital signs or assessment data C. it allows several health team members to view the patient record simultaneously D. it automatically corrects both spelling and grammar

C

A nurse is explaining to other nurses on the uint about diagnosis-related groups. On what documentation do insurance companies base their payment approval/disapproval? A. medical diagnosis B. laboratory diagnosis C. diagnosis codes D. narrative notes

A

A nurse, new to the hospital, is attending orientation with the nurse educator who is discussing the use of PIE charting in the documentation of patient care. How would the nurse educator best describe PIE? A. problem, interventions, and evaluation B. position, intervention, and evaluation C. position, intervention, and exit note D. problem, intervention, and exit note

outcomes and assessment information set

OASIS

computerized provider order entry

CPOE

D

During an accrediting agency visit, it is found that some patient care standards are not being met. Where should problem solving occur in this instance? A. Patient level B. Shift level C. Department level D. Facility level

sentinel event

a serious, often life threatening, error in health care

situation, background, assessment, recommendation

SBAR

subjective, objective, assessment, plan

SOAP

D

The nurse is caring for a patient with a terminal illness. What would be the purpose of convening a family care conference? A. to agree on when care begins B. to coordinate schedules C. to determine what assessment data to include in a report D. to coordinate all aspects of the patient's care

C

What statement about batch charting is most accurate? A. it provides clear documentation B. it makes the chart available to multiple users C. it contributes to many potential errors D. it facilitates completion in a timely manner

B

Why is accurate and effective documentation most important? A. it keeps patients informed about their care B. documentation constitutes a legal record C. it ensures that data can be used for research purposes D. it can be used to educate other nurses

clinical pathway

a multidisciplinary tool that identifies a standard plan for a specific patient population

never event

a preventable error, treatment of which is not reimbursed by medicare and medicaid