CHAPTER 17 DOCUMENTING, REPORTING, CONFERRING, AND USING INFORMATICS 93
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:
3.Briefly explain the following purposes of the
patient record.
a.Communication:
b.Care planning:
c. Quality review:
d.Research:
e.Decision analysis:
f. Education:
g.Legal documentation:
h.Reimbursement:
i. Historical document:
4.List five guidelines nurses should follow when
reporting a significant change in a patient’s
condition to other healthcare professionals by
telephone.
a.
b.
c.
d.
e.
5.List four benefits of using the Resident Assess-
ment Instrument (RAI).
a.
b.
c.
d.
- A nurse documents that a patient is
homebound and still needs nursing care. - A nurse uses RAI to document care.
SHORT ANSWER
1.List four areas of nursing care data that, accord-
ing to the Joint Commission, must be perma-
nently integrated into the patient record.
a.
b.
c.
d.
2.Briefly describe the following methods of
reporting patient data.
a.Change-of-shift reports:
b.Telephone reports:
c. Telephone orders:
d.Transfer and discharge reports:
e.Reports to family members and significant
others:
f. Incident reports:
g.Conferring about care:
h.Consultations and referrals:
i. Nursing care conference:
j. Nursing care rounds:
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