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Documentation Questions and Answers (Q&A)

Bobby Rickets, Content Reviewer
Answered: Jun 20, 2019
The correct answer to this question is C, Data entry. Adding information to a person's health care record is very important. It keeps every informed and up to date on what has been done, and it...Read More

4 Answers

226 views
L. Brett, Sales Manager
Answered: Jan 25, 2019
The DARE format is known to be something that nurses refer to when they want to do proper documentation of effects regarding their patients. There are certain things that will be discussed such...Read More

3 Answers

233 views
H. Jones, Web Content Writer
Answered: Jul 16, 2018
The answer here for this question would be the first option and that is that the traditional way of medical record charting has an abbreviated story where the problem oriented version of charting...Read More

3 Answers

273 views
John Smith
Answered: Feb 24, 2020
Kardex or Rand
2. Nursing Care Plan
3. Incident Reports
4. 24-hour patient care and acuity charting
5. Discharge summary

Pages 145-149

2 Answers

204 views
E.Ruth
Answered: Feb 19, 2018
D. Focus can be a medical diagnosis Focus charting is used to describe a perspective of a patient. It is a method that health professionals used to organize the records of a patien...Read More

2 Answers

203 views
John Smith
Answered: Feb 24, 2020
If a charting error is made, draw one line through the faulty information
2. Chart only your own care even when someone else calls you for a late entry.
3. Chart after care is provided, as...Read More

2 Answers

241 views
John Smith
Answered: Feb 24, 2020
Allows staff to develop standardized integrated care plans for a projected length of stay for patients of a specific case type.
Clinical pathways that delve with cases occur in high volume...Read More

2 Answers

205 views
John Smith
Answered: Feb 24, 2020
Additional treatments done or planned treatments withheld
2. New Concerns
3. Changes in patient condition

P. 145

1 Answer

203 views
John Smith
Answered: Feb 24, 2020

1. Each time you give a medication
2. Each time a bath is given
3. Each time you assess vital signs

1 Answer

205 views
John Smith
Answered: Feb 24, 2020
Charting interventions in advance to save time
Documenting incorrect data
Not charting the correct time when events took place
Not recording verbal orders or not having them signed....Read More

1 Answer

207 views
John Smith
Answered: Feb 24, 2020
Sometimes used by government agencies to evaluate patient care
It is a permanent record for accountability
It is a legal record of care
Can be used for research, teaching and data...Read More

1 Answer

205 views
John Smith
Answered: Feb 24, 2020
Admission sheet and physician s orders
2. Progress notes and nurse s admission information
3. History and Physical Examination Data
4. Care plan and nurse s notes

P. 142

1 Answer

201 views
John Smith
Answered: Feb 24, 2020
It provides a narrower scope of people for a wider majority of services.
Requires a whole health care team to work closely
Duplication of documentation is difficult to avoid

P. 151

1 Answer

210 views
Wyatt Williams
Answered: Feb 24, 2020
PIE is from a nursing process. SOAPE is from a medical model

P. 145

1 Answer

202 views
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