92 UNIT III THE NURSING PROCESS
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:
DEVELOPING YOUR
KNOWLEDGE BASE
FILL-IN-THE-BLANKS
1.A(n) is a compilation of a
patient’s health information.
2.The usual format for charting is
the unexpected event, the cause of the event,
actions taken in response to the event, and
discharge planning if appropriate.
- are a key component to facilitate
data and outcome comparisons. They are spe-
cific categories of information that use
uniform definitions to create a common
language among multiple healthcare data
users.
4.The is a group of data elements
that represent core items of a comprehensive
assessment for an adult home care patient and
form the basis for measuring patient outcomes
for purposes of outcome-based quality
improvement.
5.Documentation in long-term care settings is
specified by the , which helps the
staff gather definitive information on a
resident’s strengths and needs and address
these in an individualized plan of care.
6.A nurse who communicates oral, written, or
audiotaped patient data to the nurse replacing
him/her on the next shift is giving a(n)
report.
7.A(n) is a tool used by healthcare
agencies to document the occurrence of
anything out of the ordinary that results in, or
has the potential to result in, harm to a
patient, employee, or visitor.
8.A(n) is a meeting of nurses to
discuss some aspect of a patient’s care.
MATCHING EXERCISES
Match the formats of nursing documentation
listed in Part A with their appropriate example
listed in Part B.
PART A
a.Initial nursing assessment
b.Plan of nursing care
c.Critical/collaborative pathways
d.Progress notes
e.Graphic record
f.24-hour fluid balance record
g.Medication record
h.24-hour nursing care record
i.Discharge and transfer summary
j.Home care documentation
k.Long-term care documentation
PART B
- The nurse documents the case manage-
ment plan for a patient population with
a designated diagnosis, which includes
expected outcomes, interventions to be
performed, and the sequence and timing
of these interventions. - The nurse documents a diabetic
patient’s intake and output of fluids. - The nurse summarizes a patient’s reason
for treatment, significant findings,
procedures performed and treatment
rendered, and any specific instructions
for the patient/family. - The nurse uses this form to record a
patient’s pulse, respiratory rate, blood
pressure, body temperature, weight, and
bowel movements. - The nurse documents routine aspects of
care that promote goal achievement,
safety, and well-being. - The nurse records the database obtained
from the nursing history and physical
assessment. - The nurse documents the
administration of Cipro IV, 400 mg
every 12 hours. - The nurse documents a patient’s diagno-
sis of AIDS, expected outcomes, and
specific nursing interventions.
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