Nur 102 CH 15

Which documentation tool will the nurse use to record the patient's vital signs every 4 hours?

A graphic sheet

the process of sending or guiding the client to another source for assistance.

A referral

Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

Among the provisions of HIPAA are clients' rights to see and read their medical records and read the documentation that his physician wrote in his chart.

Be sure to include what essential information when charting:

Assessments Nursing interventions Medications given Physician's orders carried out Physician notification of change in patient's status Patient teaching Patient responses Any change in the plan of care

Waiting until the end of the shift to record events on several patients, known as

Batch charting

Models for ensuring quality of care, providing direction about major interventions to perform for a specific condition

Clinical Pathways

transfer of care for a patient from one health provider to another, significantly increases the risk of errors.

Hand offs

A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)?

Minimum data set

is a progress note that relates to only one health problem. All healthcare team members use the same format.

SOAP note

What organization audits patient records regularly and requires that institutions set up ongoing quality assurance programs as part of accreditation requirements.

The joint commission

written forms of communication

kardex, checklist, nursing care plan, and flow sheets.

Review of records

Audit

allows authorized providers to enter all orders directly into the computer, electronically communicating orders to the laboratory, pharmacy, and nursing personnel

Computerized Physician (Provider) Order Entry (CPOE)

initial and ongoing assessment of all patients they care for to qualify for Medicare or Medicaid reimbursement

Outcome and Assessment Information Set (OASIS)

communicate verbally to the healthcare provider. Situation, Background, Assessment, and Recommendation. This is the communication tool to provide critical client information to the healthcare provider.

SBAR

approves specific vocabularies as appropriate for nursing practice. At this time, these vocabularies include Omaha, Nursing Interventions Classification (NIC), Nursing Outcomes Classification (NOC), Home Health Care Classification (HHCC), NANDA-I, and Ozbolt's Patient Care Data Set (PCDS).

The American Nurses Association (ANA)

Record of a client's health saved on and easily accessed by computer system

computer-based personal record (CPR)

Documentation that takes place as care occurs

point of care (POC) documentation

a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake, and output, and bowel movement.

Graphic sheet

A nurse charting the medical record for a client knows that which of the following forms of charting involves writing information about the client and client care in chronological order?

Narrative charting

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have what drawback?

Vulnerability to legal liability since nurse's safe, routine care is not recorded

interfaces medication orders with pharmacy dispensing and allows direct computer charting of medication administration

electronic medication administration record (eMAR

Medicare and Medicaid stopped reimbursement for some hospital-acquired complications that were deemed reasonably preventable through the use of evidence-based guidelines. These complications, include

foreign objects left in the body after surgery, air emboli, infusion of incompatible blood, falls resulting in trauma, catheter-associated urinary tract infections, certain infusion-associated infections, and pressure ulcers, have been referred to as Never Events since they should never occur

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, patients

have the right to copy their health records.

Reports used to assess patterns of errors and the need to change the procedures involved

quality assurance memos