38 Questions
What is the acceptable format for recording assessments according to the text?
Electronic or paper form
Who may need to be verbally reported to in case of abnormal findings?
The health care team
What is the most responsible provider to whom abnormal findings may need to be reported?
Physician or Nurse Practitioner
Which type of assessments may involve reporting to the police according to the text?
Abnormal findings assessments
Who determines the set of rules on documentation according to the text?
The College of Nurses of Ontario
What is the purpose of the 'History of current illness' section?
To provide a chronological record of relevant symptoms and characteristics
What is the nurses' responsibility regarding documentation of client care?
To ensure documentation is accurate, clear, and comprehensive
What is an important aspect of nurses' accountability for documentation?
Ensuring documentation is timely and complete
What is included in the 'Past health history' section?
Complete record of allergies, current medications, and childhood illnesses
What is the order of the examination of body systems in the 'Review of systems' section?
Approximately head to toe
How do nurses safeguard client health information?
By maintaining confidentiality and following information retention policies
What should nurses do if they forget to document at the right time?
Sign it late when they remember to do it
What is assessed in the 'Functional assessment' section?
Patients' self-care ability and activities of daily living
What is the purpose of using appropriate abbreviations and symbols in documentation?
To ensure each has a distinct interpretation and appears in a list with full explanations
What kind of information is included in the 'Family history' section?
Ages and health of family members, date and cause of death, and relevant-shared illness related to RSC
What is the difference between signs and symptoms?
Signs are objective observations, while symptoms are subjective sensations.
What does the 'onset' relate to when gathering information from the patient?
When and what happened to cause the symptoms.
What is meant by 'palliative and provocative' in the context of reporting to the healthcare team?
What makes the symptoms better or worse.
What does 'radiation and region' refer to in reporting the patient's condition?
The location and how the symptoms are shown.
Why is it important to understand the 'associated signs and symptoms' when reporting to the healthcare team?
To identify other symptoms related to the patient's condition.
What is the purpose of collecting subjective data in health history?
To obtain information given by the patient's perspective
What does the term 'biographical data' in health history refer to?
Information about the patient, such as age, birthdate, and address
In which type of health history does the nurse focus on only what the patient complains about or reason for seeking care?
Focused health history
What is the role of the nurse in obtaining the health history 'source of Hx'?
To verify key information about the patient
What type of health history uses only yes/no answers and is considered urgent?
Emergency history
What does the term 'substitute decision maker' refer to in the context of health history?
Legal position for making decisions on behalf of the patient
What category of subjective data includes information given by the patient?
'Patient's perspective'
Where does a nurse focus solely on what the patient complains about or reason for seeking care?
'Focused health history'
In which type of health history does a person new to a hospital have to provide data in every single 12 categories?
'Complete health history'
What is the purpose of the health history?
To collect subjective data: what the patient says about himself, herself, or themselves
Which type of health history focuses on only what the patient complains about or reason for seeking care?
Focused health history
What is included in the 'Biographical data' category of the health history?
Recent gender identity and relationship status
What does the term 'Substitute Decision Maker' refer to in the context of health history?
The individual making healthcare decisions on behalf of the patient
What category of subjective data includes information given by the patient?
'History of current illness'
In which type of health history does a person new to a hospital have to provide data in every single 12 categories?
'Complete health history'
What is the purpose of collecting subjective data in health history?
To collect information given by the patient
What does 'Source of Hx' refer to in the context of health history?
Who is providing the health history and their relationship
What is focused on in the 'Emergency history' type of health history?
Uses only yes/no answers. Urgent
Test your knowledge on nursing documentation, communication, accountability, and security practices. Ensure that you understand the importance of accurate, clear, and comprehensive documentation, along with accountability for timely and complete records, and maintaining confidentiality of client health information.
Make Your Own Quizzes and Flashcards
Convert your notes into interactive study material.
Get started for free
