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Flashcards in Final 106 Deck (29)
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1
Q

What is a guideline for legally sound documentation?

A

If an order is questioned record that clarification was sought.

2
Q

Guidelines for documentation and reporting…

A

Factual, accurate, complete, current and organized.

3
Q

Method of charting where nurse writes a progress note only when the standardized statement on the form is not met…

A

Charting by exception, nurse only documents significant findings or exceptions to the predefined norms.

4
Q

Purposes of the clients medical record include…

A

Education and research

5
Q

Nurse instructor helping student with discharge planning and realizes student needs more education when this statement is made…

A

“I can’t start discharge planning until physician writes discharge order.” This is wrong because discharge planning starts on admission.

6
Q

What should nurse record as achieved expected outcome?

A

Client ate 50% of lunch. Clients intake is an outcome.

7
Q

The type of care management approach that coordinated health care services while streamlining costs?

A

Case management.

8
Q

The team member essential for empowering a nursing team?

A

Clinical nurse specialist.

9
Q

Case management approach to client care is unique because?

A

Clinicians oversee the management of clients with specific case types.

10
Q

Client experiencing anxiety attack, what priority is this?

A

High priority.

11
Q

Client that can be assigned to LPN?

A

The client who had vaginal hysterectomy 2 days ago.

12
Q

What should NOT be included in discharge summary?

A

Interventions performed by PT 2 days ago.

13
Q

When does discharge planning begin?

A

When client admitted.

14
Q

Nurse performing admission assessment, after gathering data what is priority?

A

Orient client to room.

15
Q

American Nurse Agency

A

Is not a healthcare regulatory agency.

16
Q

Utilization review committee purpose?

A

Review admissions, diagnostic tests, and treatment ordered by physicians.

17
Q

Emergency services

A

Secondary

18
Q

Immunizations

A

Prevention

19
Q

Cancer center

A

Tertiary

20
Q

School screenings

A

Primary

21
Q

Home health care

A

Restorative

22
Q

Hospice

A

Continuing

23
Q

Assistive personnel cannot obtain?

A

Sterile urine specimen.

24
Q

Client in managed care organization (MCO) requires hospitalization, admission must be approved by?

A

The provider

25
Q

Evidenced based practice is NOT?

A

Only based on the results of research.

26
Q

Clients health insurance changed, now he is enrolled in a plan where medical care is provided by a special group of caregivers?

A

Managed care organization MCO

27
Q

What was the most significant in influencing competition in health care costs?

A

Prospective payment system.

28
Q

Nurse volunteers to take BP after church, this is an example of?

A

Illness prevention.

29
Q

Hospital conducts community BP in lobby this is?

A

Primary care