Study Guide for Fundamentals of Nursing The Art and Science of Nursing Care

CHAPTER 17 DOCUMENTING, REPORTING, CONFERRING, AND USING INFORMATICS 93

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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i. Historical document: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.

9. A nurse documents that a patient is
   homebound and still needs nursing care.


10. 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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