Save
Busy. Please wait.
Log in with Clever
or

show password
Forgot Password?

Don't have an account?  Sign up 
Sign up using Clever
or

Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
Your email address is only used to allow you to reset your password. See our Privacy Policy and Terms of Service.


Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.
focusNode
Didn't know it?
click below
 
Knew it?
click below
Don't Know
Remaining cards (0)
Know
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

NRS Documentation

test 1

QuestionAnswer
Purpose of the chart communication, permanent record for accountability, peer review, reimbursement, legal record of care, teaching tool, and research and data collection
Types of patient records source-oriented and problem-oriented
source-oriented chart each healthcare discipline documents in their own section
Problem-oriented chart based on scientific problem-solving method; organized according to the health problem
problem oriented chart includes database,problem list, plan of care, and progress notes (everybody documents here)
methods of charting narrative style, SOAPE/SOAPIER, Focus, PIE, charting by exception
charting by exception only abnormal assessment findings are documented; effort to decrease length and repetition
PIE charting Problem Intervention Evaluation
Focus charting DARE Data Action Response Education
SOAPE/SOAPIER charting Subjective Objective Assessment Plan Evaluation Intervention Revision
Narrative charting descriptive form including pt. problem, care and treatment provided; as well as pt. response
computer charting pros/cons PROS fast, legible, auto date/time CONS can risk confidentiality, can be hard to make corrections if not made quickly
T or F never use military time False
00:00= midnight or 12am
12:00= 12pm or noon
18:00= 6pm
23:00= 11pm
1am 01:00
6am 06:00
T or F Rn is responsible for initial assessment upon admission True
T or F any sheet patient info is documented on may only include the patient date of birth False. It should have their at least their name on every page
T or F when in doubt write it out True
when giving medications, especially PRN... Always chart follow-up response 30 minutes after
T or F Empty lines in a chart are okay if there is nothing to note False. Any skipped lines or empty lines should at least have a line drawn through them to avoid additions at later times.
T or F chart as soon as you can, even if it is prior to giving care False. only chart after care is given and as soon as possible after
Do you have to chart the type of transportation device used to transfer or discharge a pt.? yes.
Can you chart deviations without and explanation? No. there needs to always be an explanation of any deviations from the original care plan.
should you document any time the physician was contacted? Yes.
Created by: laceynickie
Popular Nursing sets

 

 



Voices

Use these flashcards to help memorize information. Look at the large card and try to recall what is on the other side. Then click the card to flip it. If you knew the answer, click the green Know box. Otherwise, click the red Don't know box.

When you've placed seven or more cards in the Don't know box, click "retry" to try those cards again.

If you've accidentally put the card in the wrong box, just click on the card to take it out of the box.

You can also use your keyboard to move the cards as follows:

If you are logged in to your account, this website will remember which cards you know and don't know so that they are in the same box the next time you log in.

When you need a break, try one of the other activities listed below the flashcards like Matching, Snowman, or Hungry Bug. Although it may feel like you're playing a game, your brain is still making more connections with the information to help you out.

To see how well you know the information, try the Quiz or Test activity.

Pass complete!
"Know" box contains:
Time elapsed:
Retries:
restart all cards