Health Care > EXAM > NUR 155 EXAM ONE EXAM 2023 Full and Revised Study Guide with Complete solutions (All)

NUR 155 EXAM ONE EXAM 2023 Full and Revised Study Guide with Complete solutions

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NUR155 EXAM ONE STUDY GUIDE Exam One Study Guide With Complete Solutions Documenting and Reporting: Chart For everyone to see that is caring for patient, only look at charts of patients you need to... know about. • can be formal or informal • oral written or computerized • chart is a legal record Legal considerations: • chart is legally protected • organization owns • patient has rights to chart • restricted access HIPPA: • Health insurance portability and accountability act 1996;amended 2003 • Duty is to protect PHI- Protected health information Computerized records: • Cerner • Epic • Meditech Purpose of records (DRG) diagnosed related group • Communication, planning client care, research • Auditing, reimbursement, legal documentation • Education, health care analysis Documentation Systems • Source oriented record: traditional, each department or individual has their own section • Narrative: component of source oriented, no right or wrong order; chronological used Problem Oriented medical record- POR • 4 basic components: • Database: known when pt 1st enters health care facility, nursing assessment, primary care history, social & family data, baseline physical exam & diagnostic test. • Problem list: derived from database. Caregivers contribute, physiological, psychological, social, cultural, spiritual, development, and environmental needs. Medical problems, diagnoses, surgical procedures, symptoms; nurse diagnoses. (ex impaired mobility, urinary incontinence). • Plan of Care- Initial list of orders or plan of care. • Progress notes- chart entry’s made by ALL Health care professionals involved in patients care. SOAP or SOAPIER- Subjective- obtained from client, Objective-information measured or observed (vital signs, lab, x-ray). Assessment- conclusions drawn subjective and objective from data (clients condition and level of progress). Plan- plan designed to resolve stated problem. I- intervention, E- evaluation, R- revision. PIE- Problems Interventions Evaluation • Consists or patient flow sheets and progress notes DAR- Data Action Response • Focus charting- intended to make patient concerns and strengths the focus of care CBE- Charting by Exception • Only abnormal or significant findings, exceptions to the norms recorded. 3 key elements: Flow sheets (vitals, head and face assessment) Standards of care- unconscious patient oral care q4h. Beside access chart forms- all flow sheets kept at patients bedside for immediate recording. *Guidelines for recording • Date/ time • Legibility • Permanence-Ink • Accepted terminology • Signature, Accuracy and completeness *SBAR • S- situation- state your name, unit, patient name, briefly state problem • B- background- admission diagnoses, medical history, summary of tx to date, code status • A- assessment- vital signs, pain scale, change from prior assessment [Show More]

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