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68WM6 Documentation Fill In The Blanks

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In each blank, try to type in the word that is missing. If you've typed in the correct word, the blank will turn green.

If your not sure what answer should be entered, press the space bar and the next missing letter will be displayed.

When you are all done, you should look back over all your answers and review the ones in red. These ones in red are the ones which you needed help on.
Question: careAnswer: Chief complaint; subjective and findings; diagnosis; treatment plan; response to treatment.
Question: Condition Answer: Professionals have an obligation to recognize condition change and take action. Can only illustrate this through .
Question: The is used as a Answer: utilization
Question: , Objective Notations areAnswer: What you hear, see, feel, and .
Question: Answer: You may be asked whether or not you tampered with the record when the record is .
Question: A lawyer may ask you this in regards to editing a document in court.....Answer: More it is, “Did you alter the record in any way?.” This is much broader.
Question: Drug Answer: Units vs. a zero (always out units).
Question: Why use zero for decimals? Answer: (ensures is recognized).
Question: If it is documented, it is to be Answer:
Question: Is it okay to ahead of time?Answer: document ahead
Question: Grammar and cleanliness are : messy notes give an appearance of Answer: care.
Question: When a patient does not cooperate with care what can we do in the patient chart?Answer: Use quotes when possible to illustrate the non-compliant .
Question: If a patient wants to against medical advice what should you do?Answer: every detail and advise the patient of the consequences. If possible, try to get patient to sign refusal of care document.
Question: An LVN can only what kind of orders?Answer: orders
Question: Telephone and Verbal orders can only be by whom?Answer: RN's
Question: Medication must includeAnswer: name.Dose.Route.Frequency.
Question: AssessmentAnswer: a systematic and continuous collection, and communication of pt
Question: DiagnosisAnswer: an analysis of pt data to identify patient strengths and health problems identified which independent nursing can prevent or resolve.
Question: PlanningAnswer: the establishment of pt goals to prevent, reduce, or resolve the problems identified in the nursing diagnoses. The nsg dx the development pertinent nsg interventions.
Question: ImplementationAnswer: putting into practice the plan of
Question: Answer: measurement of the to which the patient has achieved the goals specified in the plan of care.
Question: Assesment (Complete):Answer: provides baseline information which includes Physical examination of all body systems. Appropriate for stable patients.
Question: concentration of attention on the part of the body where signs and symptoms are localized or most active in order to determine their .Answer: Focused
Question: assesments are appropriate for...Answer: ill, disoriented, or unable to respond patients.
Question: AssesmentAnswer: systematic -up is required when problems are identified during a comprehensive or focused assessment.
Question: Subjective Answer: verbal from the patient.
Question: Objective Answer: observable and measurable which can be .
Question: Primary Source of Answer: patient. Collected from patient interview and examination.
Question: Secondary of InformationAnswer: family members, significant others, health care team, medical records, diagnostic , and nursing literature.
Question: Data Answer: process of putting data together in order to identify areas of the 's problems and strengths. Mixing all your data together like a tasty martini
Question: Hierarchy of (Maslow's)Answer: individual's basic needs must be meet before higher-level can be met.
Question: Actual DiagnosisAnswer: a condition that is currently .
Question: RiskAnswer: is a clinical judgement that an individual, , or community is more vulnerable to develop the problem than others in the same or similar situation.
Question: PossibleAnswer: when a is considered feasible.
 
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