Nursing Documentation Quiz

<p>Their competency (A)</p> Signup and view all the answers

<p>Creating competition among healthcare facilities (D)</p> Signup and view all the answers

<p>Brevity and conciseness (C)</p> Signup and view all the answers

<p>Patient advocacy (B)</p> Signup and view all the answers

<p>Taking ownership of actions (C)</p> Signup and view all the answers

<p>Lengthy descriptions (B)</p> Signup and view all the answers

<p>Making decisions based on evidence (C)</p> Signup and view all the answers

<p>To provide data for the health team (A)</p> Signup and view all the answers

<p>It influences decisions on care provided and agency funds (A)</p> Signup and view all the answers

<p>Data is used to inform the entire health team’s care planning (C)</p> Signup and view all the answers

<p>To solely ascertain clinical staff shortages (D)</p> Signup and view all the answers

<p>By establishing guidelines for agency reimbursement (C)</p> Signup and view all the answers

<p>Problem solving format for health status recording (B)</p> Signup and view all the answers

<p>It often requires sorting through data to locate information (C)</p> Signup and view all the answers

<p>Chronological Record Keeping (C)</p> Signup and view all the answers

<p>Skill in synthesizing data to locate required information (A)</p> Signup and view all the answers

<p>By providing a structured problem-solving format (B)</p> Signup and view all the answers

<p>Objective (C)</p> Signup and view all the answers

<p>Care provider’s understanding of the problem (B)</p> Signup and view all the answers

<p>Goals, action, and advice (D)</p> Signup and view all the answers

<p>Intervention, Evaluation, Revision (B)</p> Signup and view all the answers

<p>To identify and modify care strategies (A)</p> Signup and view all the answers

<p>After the RN's review (D)</p> Signup and view all the answers

<p>Continuing problems (A)</p> Signup and view all the answers

<p>Analysis of laboratory results (B)</p> Signup and view all the answers

<p>DAR (C)</p> Signup and view all the answers

<p>Response of the client (C)</p> Signup and view all the answers

Provides knowledge and skills for students in the healthcare field.

Tracks the quality of care given to patients and the abilities of the healthcare providers.

Written records that document patient care, procedures, and outcomes.

The act of creating and sharing information relating to patient care.

Systematic process of evaluating healthcare quality to improve patient outcomes.

Planning Client Care uses data that the entire healthcare team relies on to create a plan for the patient's care.

Reimbursement is the process of getting paid back for healthcare services provided. The agency gets reimbursed for expenses.

Planning Client Care helps healthcare team members understand the patient's needs and coordinate their efforts.

Reimbursement helps agencies stay financially stable and continue providing care.

Reimbursement can influence the types of services provided, as agencies need to make sure they can get paid.

Nursing skills and judgment demonstrate the unique value nurses bring to healthcare.

Nursing involves accountability, meaning nurses are responsible for their actions and decisions.

Good documentation is accurate, timely, legible, objective, complete, and confidential.

Documentation is a vital part of nursing, and includes written or electronic records of patient care.

Accurate and timely reporting of patient information is crucial for safe and effective care.

Observations made by the patient themself about their health.

Observations made by the healthcare professional using tools like tests, vitals, and examinations.

The healthcare provider's analysis of the problem based on subjective and objective observations.

A plan of action that includes goals, interventions, and advice for the patient.

A method of documenting interventions, evaluations, and revisions in patient care.

A way of organizing patient records that focuses on identifying and addressing specific health problems.

A system of documenting patient care using a specific format, such as a SOAP note or a flow sheet.

Data about a patient's health status that is used to make decisions about care.

Information about a patient's health that is collected, analyzed, and shared to improve care.

A logical approach to documenting patient care that helps ensure clear and complete information.

A nursing documentation method where nurses document data, interventions, and patient responses.

This documentation method focuses on the client's subjective and objective data, the actions taken by the nurse, and the client's response to those actions.

Problems identified during a patient's care that are documented daily until they are resolved.

Problems identified during a patient's care that are resolved and removed from daily documentation.

The process of recording patient observations, interventions, and responses in a systematic way.