Ch3 Documentation (1)

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Upper Valley Educators Institute *

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Course

1272

Subject

Chemistry

Date

Feb 20, 2024

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pdf

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4

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Ch 3 Documenta�on Matching __D__1. CBE __I__2. DRGs __F__3. EHR __J__4. HIPAA __G__5. MDS __H__ 6. POC __B__ 7. DARE __C__ 8. SBARR __A__ 9. PIE __E__10. SOAPE a. Plan, interven�on, evalua�on b. Data, ac�on, response, educa�on c. Situa�on, background, assessment, recommenda�on, read back d. Char�ng by excep�on e. Subjec�ve, objec�ve, assessment, plan, evalua�on f. Electronic health record g. Minimum data sets h. Point of care i. Diagnosis - related groups j. Health Insurance Portability and Accountability Act Open Book Quiz 1) Name the five basic purposes for writen pa�ent records. Documented communica�on, Permanent record for accountability, Legal record of care, Teaching, and Research and data collec�on. 2) What is a diagnosis - related group? A System that classifies pa�ents by age, diagnosis, and surgical categories; used to predict the use of hospital resources including the length of stay.
3) List the four common issues in malprac�ce caused by inadequate documenta�on. Not char�ng the correct �me that events occurred of that and event occurred at all, failing to record verbal orders, char�ng nursing care in advance, and documen�ng incorrect data. 4) Define narra�ve char�ng and describe what is included in its implementa�on. Tradi�onal system of char�ng in which the nurse documents in story form all per�nent pa�ents, observa�ons, care and responses in the nurse notes sec�on of pa�ents records. 5) What does the acronym SOAPIER describe? Format used in POMR. Components include Subjec�ve data (S) reported by the pa�ent, Objec�ve data (O) acquired by inspec�on, percussion, ausculta�on, and palpita�ons, and by test, usually measurable findings; Assessment (A) of the problem; Plan (P) of care; Interven�on (I); Evalua�on (E) of the pa�ent s response to the treatment plan; Revisions (R) changes made. 6) How is the focus char�ng format used? It is used by using the nursing process and more posi�ve concept of the pa�ent’s needs rather than medical diagnoses and problems. (DARE) Data, Ac�on, Response and evalua�on, Educa�on. 7) What are the procedures a nurse should follow when filling out an incident report? 8) Describe acuity char�ng and explain why it is used. It rates the pa�ent’s severity of illness and determines efficient staffing paterns. 9) Who has ownership and access rights to health care records? The original health record or chart is the property of the ins�tu�on or health care provider. 10) What are the major concerns regarding electronic documenta�on? Confiden�ality, access to informa�on and inappropriate alterca�ons in pa�ent records are areas of concern. NCLEX REVIEW QUESTIONS 1. What is considered an appraisal by a professional co - worker of the manner in which an individual nurse conducts prac�ce, educa�on, or research? a. Peer review b. Assessment
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