Problem-Oriented Medical Record Quiz & Flashcards

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Questions and Answers

What is the primary purpose of a Problem-Oriented Medical Record?

To reveal that appropriate care has been given (correct)

To keep track of the client's progress notes

To ensure the correct diagnosis-related group codes are included

To organize data based on source information

What does the problem list in the front of the chart do?

Serves as an index to the numbered entries in the progress notes

Alerts caregivers to the client's needs (correct)

Generates care plans for caregivers

Organizes data based on the source of information

Who generates care plans in a Problem-Oriented Medical Record?

The facility's administration

The health professionals involved in the client's care (correct)

The client themselves

The federal government

What is a disadvantage of a Problem-Oriented Medical Record according to the text?

Constant vigilance needed to maintain an up-to-date problem list (A) Signup and view all the answers

How are Progress Notes typically recorded in a Problem-Oriented Medical Record?

By using a numbering system to correspond with problems (B) Signup and view all the answers

What information is emphasized in a Problem-Oriented Medical Record?

Problems the client has rather than the source of the information (C) Signup and view all the answers

What is the purpose of a change-of-shift report?

To provide continuity of care for clients (C) Signup and view all the answers

What should nurses focus on when documenting in the change-of-shift report?

Documenting only information about the clients' health problems care (D) Signup and view all the answers

Why is it important to be concise in a change-of-shift report?

To clearly state priorities of care and tasks due (C) Signup and view all the answers

What type of information should be included in the change-of-shift report?

Current orders from the nurse and physician (A) Signup and view all the answers

In which format can a change-of-shift report be given?

Either in face-to-face exchange or by audiotape recording (C) Signup and view all the answers

What is considered an invasion of the client's privacy in a change-of-shift report?

Recording irrelevant information (B) Signup and view all the answers

What is the most appropriate action when receiving an ambiguous order from a primary care provider?

Repeat the order back to the sender for confirmation. (D) Signup and view all the answers

When transcribing a medication order, what is the recommended action if you are unfamiliar with the drug?

Ask the prescriber to spell out the medication name. (D) Signup and view all the answers

Which statement about units of measurement is correct when transcribing orders?

Write out units in full (e.g., 15 units of insulin). (A) Signup and view all the answers

What is the appropriate action when receiving a voice mail order from a prescriber?

Disregard the voice mail order and wait for a written order. (C) Signup and view all the answers

What is the primary purpose of nursing rounds?

To obtain information for planning client care. (B) Signup and view all the answers

When transcribing an order, which statement is true regarding obtaining the prescriber's signature?

The prescriber's signature is optional, follow agency protocol. (A) Signup and view all the answers

What is the appropriate way to document a telephone order?

Write the complete order on the physician's order sheet, record the date, time, and indicate it was a telephone order (TO), then sign with name and credentials. (C) Signup and view all the answers

Who is authorized to accept telephone orders?

Only registered nurses as per nursing board regulations (C) Signup and view all the answers

When giving a telephone report, what should be included?

Identify yourself, state your role, the patient's name, and the relevant information concisely and accurately (C) Signup and view all the answers

How should dosages be written when documenting telephone orders?

Use a leading zero before a decimal, e.g., 0.5ml (C) Signup and view all the answers

What should be done when receiving an unusual or contraindicated telephone order?

Clarify the order with the provider and document any concerns or clarifications (C) Signup and view all the answers

What should be done after receiving and documenting a telephone order?

Read back the order to the provider to ensure accuracy (D) Signup and view all the answers

Why is it essential to make sure that all entries in the client's record are legible and easy to read?

To prevent errors in interpretation (B) Signup and view all the answers

In which color ink should entries be made in the skin assessment record according to the text?

Black ink (B) Signup and view all the answers

Which of the following is NOT included in medication flow sheets according to the text?

Client's blood pressure reading (A) Signup and view all the answers

What is the purpose of complete signatures on nursing notes according to the text?

To protect the nurse legally (A) Signup and view all the answers

Why does recording need to be brief and concise according to the text?

To maintain accurate and precise records (D) Signup and view all the answers

What is the main reason for recording timing accurately in a client's record according to the text?

Legal requirements and client safety (C) Signup and view all the answers

Study Notes

Problem-Oriented Medical Record (POMR)

Primary purpose is to organize and track patient information by specific problems for better patient management and care.
The problem list at the front of the chart provides a quick reference to the patient's significant issues, facilitating easier access and understanding.
Care plans in a POMR are generated by healthcare providers involved in the patient's care, often reflecting collaborative input from the healthcare team.
A disadvantage of POMR is that it can lead to fragmentation of care since different professionals may focus on different problems without a holistic view of the patient.

Progress Notes

Progress notes in a POMR are typically recorded using the SOAP format (Subjective, Objective, Assessment, Plan), providing structured documentation.
Emphasis is placed on current patient problems, interventions performed, and responses to treatment, ensuring relevant information is highlighted.

Change-of-Shift Report

The purpose of a change-of-shift report is to ensure smooth continuity of care by communicating crucial patient information among nursing staff.
Nurses should focus on significant patient updates, changes in condition, and recent interventions to provide a comprehensive summary during the report.
Conciseness is essential in a change-of-shift report to ensure critical information is communicated efficiently, minimizing miscommunication.
Included information should cover patient assessments, progress, pending tasks, and any notable concerns that require attention.
Change-of-shift reports can be delivered verbally, in writing, or through electronic means, depending on facility protocols.

Privacy and Orders

An invasion of client privacy occurs when confidential patient information is shared without consent during a change-of-shift report.
If a nursing staff member receives an ambiguous order from a primary care provider, they should seek clarification before proceeding, ensuring patient safety.
When transcribing medication orders, unfamiliarity with a drug requires the nurse to research or consult a pharmacist for verification to prevent errors.
Correct understanding of units of measurement is critical when transcribing orders, as it ensures accurate dosage administration.

Voice Mail and Nursing Rounds

Upon receiving a voice mail order from a prescriber, the nurse must document the order and follow up with the prescriber for confirmation.
The primary purpose of nursing rounds is to assess patients systematically and maintain strong communication within the nursing team.
Obtaining prescriber signatures on transcribed orders should be done in a timely manner, ensuring legal compliance and accountability.
Documentation of telephone orders should include the order details and the name of the nurse accepting the order.

Reporting and Documentation

Only authorized personnel, typically registered nurses, can accept telephone orders, ensuring clarity on who is responsible for the information.
When giving a telephone report, include patient identifier, condition, interventions done, and any changes in status.
Dosages should be written clearly, using standard conventions and avoiding abbreviations in telephone orders to prevent confusion.
Unusual or contraindicated telephone orders should prompt immediate verification with the prescriber to ensure patient safety.
After documenting a telephone order, follow up to ensure that the order is clarified and properly signed by the prescriber as soon as possible.

Documentation Standards

Legibility in client records is essential as unclear entries can lead to misinterpretations and potential harm to patients.
Skin assessment records should be made in black ink to ensure clarity and adherence to facility standards.
Medication flow sheets typically exclude personal comments or unnecessary details, focusing solely on relevant medication administration data.
Complete signatures on nursing notes are vital as they establish accountability and traceability of care provided.
Recording needs to be brief and concise to maintain focus on critical information, ensuring efficient use of documentation time.
Accurate timing in a client's record is crucial to correlate assessments with interventions and track patient progress effectively.

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Test your knowledge on the importance of documentation in problem-oriented medical records for reimbursement purposes. Learn how to organize information chronologically and accurately code diagnosis-related group codes for Medicare payments.

Problem-Oriented Medical Record Documentation Quiz

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