30 Questions
What is the primary purpose of a Problem-Oriented Medical Record?
To reveal that appropriate care has been given
What does the problem list in the front of the chart do?
Alerts caregivers to the client's needs
Who generates care plans in a Problem-Oriented Medical Record?
The health professionals involved in the client's care
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
How are Progress Notes typically recorded in a Problem-Oriented Medical Record?
By using a numbering system to correspond with problems
What information is emphasized in a Problem-Oriented Medical Record?
Problems the client has rather than the source of the information
What is the purpose of a change-of-shift report?
To provide continuity of care for clients
What should nurses focus on when documenting in the change-of-shift report?
Documenting only information about the clients' health problems care
Why is it important to be concise in a change-of-shift report?
To clearly state priorities of care and tasks due
What type of information should be included in the change-of-shift report?
Current orders from the nurse and physician
In which format can a change-of-shift report be given?
Either in face-to-face exchange or by audiotape recording
What is considered an invasion of the client's privacy in a change-of-shift report?
Recording irrelevant information
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.
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.
Which statement about units of measurement is correct when transcribing orders?
Write out units in full (e.g., 15 units of insulin).
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.
What is the primary purpose of nursing rounds?
To obtain information for planning client care.
When transcribing an order, which statement is true regarding obtaining the prescriber's signature?
The prescriber's signature is optional, follow agency protocol.
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.
Who is authorized to accept telephone orders?
Only registered nurses as per nursing board regulations
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
How should dosages be written when documenting telephone orders?
Use a leading zero before a decimal, e.g., 0.5ml
What should be done when receiving an unusual or contraindicated telephone order?
Clarify the order with the provider and document any concerns or clarifications
What should be done after receiving and documenting a telephone order?
Read back the order to the provider to ensure accuracy
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
In which color ink should entries be made in the skin assessment record according to the text?
Black ink
Which of the following is NOT included in medication flow sheets according to the text?
Client's blood pressure reading
What is the purpose of complete signatures on nursing notes according to the text?
To protect the nurse legally
Why does recording need to be brief and concise according to the text?
To maintain accurate and precise records
What is the main reason for recording timing accurately in a client's record according to the text?
Legal requirements and client safety
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.
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