Guidelines for Telephone and Verbal Orders Care Plan Conference Quiz

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What information is usually included in a Medication Administration Record?

Symptoms experienced by the patient

The expiration date of the medication (correct)

The patient's dietary preferences

Details about the patient's family

Which type of information may be found in a Skin Assessment Record?

Patient's education level

Religious beliefs of the patient

Stage of skin injury (correct)

Nutritional status of the patient

What is the purpose of Progress Notes made by nurses?

To record the patient's family medical history

To list the patient's favorite activities

To provide information on the client's response to treatment and care provided (correct)

To document the client's personal opinions

When are Nursing Discharge/ Referral Summaries usually completed?

When the client is being discharged or transferred to another setting Signup and view all the answers

Why is it important to avoid using medical abbreviations in Nursing Discharge/ Referral Summaries?

To maintain clear communication and prevent errors in interpretation Signup and view all the answers

What is the purpose of a report accompanying a client when they are transferred within or out of a healthcare facility?

To guarantee continuity of care in the new area Signup and view all the answers

What is primarily reflected in the 'E' part of the PIE model?

Reassessment data Signup and view all the answers

What happens to the care plan as a result of the 'E' part of the PIE model?

It is revised Signup and view all the answers

What is a primary difference between older and newer versions of the PIE format?

Elimination of subjective and objective data Signup and view all the answers

What is the purpose of a flow sheet in the PIE model?

To monitor specific assessment criteria Signup and view all the answers

What is used to word problems in the progress notes of the PIE model?

NANDA diagnoses Signup and view all the answers

What is an example of data that might be recorded on a flow sheet in an ambulatory clinic?

Blood glucose level once a month Signup and view all the answers

What is the purpose of a Care Plan Conference?

To allow nurses to discuss solutions to client problems Signup and view all the answers

Why is a climate of respect important during a Care Plan Conference?

To allow each nurse to offer an opinion without judgment Signup and view all the answers

What is the significance of having a primary care provider countersign a physician's order?

To adhere to agency policies and guidelines Signup and view all the answers

What happens during Nursing Rounds?

Obtain information to plan nursing care Signup and view all the answers

Why do many acute care hospitals require a primary care provider to countersign orders within 24 hours?

To ensure timely collaboration between physicians and primary care providers Signup and view all the answers

What is the primary goal of Nursing Rounds?

To obtain information for nursing care planning Signup and view all the answers

What information is typically included in a Discharge and Referral Summary?

Client's physical, mental, and emotional status Signup and view all the answers

Which of the following is NOT part of a Discharge and Referral Summary?

Recommendations for specialized care Signup and view all the answers

What is an example of information about functional/self-care abilities found in the Discharge and Referral Summary?

Meal preparation and eating capabilities Signup and view all the answers

Which type of healthcare professional might be listed in the Referral services of a Discharge and Referral Summary?

Social worker Signup and view all the answers

What does a Discharge and Referral Summary help in arranging for the client?

Follow-up appointments Signup and view all the answers

Which of the following is a potential mode of discharge mentioned in the text?

Ambulance Signup and view all the answers

What is the advantage of using Problem-Oriented Medical Record (POMR)?

Encourages collaboration and places the problem list in a visible location. Signup and view all the answers

What is a major disadvantage of using Problem-Oriented Medical Record (POMR)?

Caregivers vary in their ability to use the required charting format. Signup and view all the answers

Which component of Problem-Oriented Medical Record (POMR) holds all the client information, including assessments and test results?

Database Signup and view all the answers

How is information arranged in the Problem-Oriented Medical Record (POMR)?

According to the problems the client has Signup and view all the answers

Why do assessments and interventions need to be repeated in the Problem-Oriented Medical Record (POMR)?

As they apply to multiple problems, and POMR lacks integration Signup and view all the answers

What is the purpose of the problem list in the Problem-Oriented Medical Record (POMR)?

To serve as an index to the progress notes Signup and view all the answers