Term
| Under the prospective payment system, Medicare reimburses hospitals a set dollar amount for each |
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Definition
| diagnosis-related group (DRG) |
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Term
| a series of decision trees designed to cluster groups of clients together by diagnosis, surgical procedures, complications, comorbidities (preexisting illness), and age. |
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Definition
| A diagnosis-related group (DRG) |
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Term
| guidelines for legal recording |
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Definition
*do not erase/scratch out errors. single line cross out only
*no personal/critical comments.
*promptly correct any found errors
*record all facts
*no blank spaces on forms
*black ink only
*chart only your stuff
*name,date, time every entry
*no password sharing. |
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Term
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Definition
S—subjective data
O—objective data
O—objective data |
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Term
| what records offer a way to determine the hours of care and staff required for a given group of clients |
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Definition
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Term
| Nurses write four types of reports, |
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Definition
| change-of-shift reports, telephone reports, transfer reports, and incident reports. |
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Term
| a legal document and requires information describing the care that is delivered to a client. |
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Definition
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Term
| Accurate record keeping requires an objective interpretation of data with |
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Definition
| precise measurements, correct spelling, and proper use of abbreviations. |
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Term
| Any change in a client's condition warrants immediate |
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Definition
| documentation to keep a record accurate. |
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Term
| The medical record is a financial record that serves as the |
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Definition
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Term
| 4 charting formats (acronyms) |
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Definition
| SOAP, SOAPIE, PIE, or DAR |
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Term
| Medicare guidelines for establishing a client's home care cost reimbursement is based on |
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Definition
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Term
| The major purpose of the change-of-shift report is to |
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Definition
| maintain continuity of care. |
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Term
| A hospital information system (HIS) consists of two major types of information systems: |
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Definition
| clinical information systems (CIS) and administrative information systems. |
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Term
1. A manager is reviewing the nurses' notes in a client's medical record. She finds the following entry, “Client is difficult to care for, refuses suggestion for improving appetite.” Which of the following directions should the manager give to the staff nurse who entered the note?
1. Avoid rushing when charting an entry
2. Use correction fluid to remove the entry.
3. Draw a single line through the statement and initial it.
4. Enter only objective and factual information about the client. |
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Definition
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Term
2. A client tells the nurse, “I have stomach cramps and feel nauseous.” This is an example of what type of data?
1. Objective
2. Historical
3. Subjective
4. Assessment |
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Definition
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Term
3. As you enter the client's room, you notice he is anxious to say something. He quickly states, “I do not know what is going on; I cannot get an explanation from my doctor about the results of my test. I want something done about this.” Which of the following is most appropriate documentation of the client's emotional status?
1. The client has a defiant attitude.
2. The client appears to be upset with his physician.
3. The client is demanding and complains frequently.
4. The client stated that he felt frustrated by the lack of information he received regarding his diagnostic tests. |
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Definition
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Term
4. A primary benefit of HIPAA regulations is to:
1. Allow access of the medical record to all hospital staff
2. Limit what information must be documented in the client's record
3. Provide clients with greater control over personal health care information
4. Enable health care institutions to release any client-related information with a general client authorization |
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Definition
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Term
5. Clients frequently request copies of their medical records. The nurse understands:
1. Only the families may read the records
2. They have the right to read those records
3. They are not allowed to read those records
4. Only the health care workers have access to the records |
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Definition
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Term
6. Accurate entries are an important characteristic of good documentation. Which of the following charting entries is most accurate in the way it is written?
1. Client up, out of bed, walked down hallway with assistance, tolerated well.
2. Client up, out of bed, walked 50 feet and back down hallway, tolerated well.
3. Client up, out of bed, walked 50 feet and back down hallway with assistance from nurse.
4. Client up, out of bed, walked 50 feet and back down hallway with assistance from nurse, HR 88 and regular before exercise, 94 and regular following exercise. |
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Definition
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Term
7. Match the correct entry with the appropriate SOAP category.
S
O
A
P
Repositioned client on right side. Encouraged client to use PCA device.
The pain increases every time I try to turn on my left side.
Acute pain related to tissue injury from surgical incision.
Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. |
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Definition
Repositioned client on right side. Encouraged client to use PCA device. (P)
The pain increases every time I try to turn on my left side. (S)
Acute pain related to tissue injury from surgical incision. (A)
Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. (O) |
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Term
8. On the nursing unit at Stevens Health Center a nurse is able to access a client's medical record and review the education that nurses provided the client during an initial hospitalization and three subsequent clinic visits. This type of record system is an example of:
1. Information technology
2. Electronic health record
3. Personal health information
4. Administrative information system |
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Definition
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