Exam 2 Nursing pt 2

juniperk's version from 2016-10-02 21:02

Section 1

Question Answer
What is charting by exception (CBE) ? shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes
What is collaborative pathway?case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions
What is flow sheet?graphic record of abbreviated aspects of the patient’s condition (e.g., vital signs, routine aspects of care)
What is Focus charting?a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format
What is health information exchange (HIE)?an electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient’s vital medical information
What is ISBAR communication?a process for effective hand-off communication among health care professionals about a patient’s condition, standing for Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read back
What is Meaningful use?the use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare and Medicaid
What is Minimum data set?a standard established by health care institutions that specifies the information that must be collected from every patient
What is Narrative notes?progress notes written by nurses in a source-oriented record
What is Nursing informatics?specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice
What is personal health record (PHR)?information sheets that contain the individual’s medical history, including diagnoses, symptoms, and medications
What is PIE charting?documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P)–intervention (I)–evaluation (E) format, and evaluated each shift
What is problem-oriented medical record (POMR)?documentation system organized according to the person’s specific health problems; includes database, problem list, plan of care, and progress notes
What is progress notes?any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes
What is SOAP format?method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P)
What is source-oriented record?documentation system in which each health care group records data on its own separate form
What is variance report or incident report?a report of any event that is not consistent with the routine operation of the health care agency that results in or has the potential to result in harm to a patient, employee, or visitor
Name three exceptions show situations in which authorization is not required prior to releasing the patient’s information?Public health activities, Law enforcement and judicial proceedings, Deceased people
What is Incidental disclosure of PHI?secondary disclosure that cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of PHI.
What is Electronic Health Record (EHR)?The EHR is the patient care record created when agencies under different ownership share their data.
What is Electronic Medical Record (EMR)?An EMR is an electronic patient care record created by an agency or agencies having common ownership.

Section 2

Question Answer
What is affective learning?changes in attitudes, values, and feelings
What is andragogy? the study of teaching adults
What is cognitive learning?storing and recalling of new knowledge in the brain
What is developmental crisis?predictable patterns of behavior and change occurring throughout the lifespan
What is formal teaching?planned teaching based on learner objectives
What is informal teaching? unplanned teaching sessions dealing with the patient’s immediate learning needs and concerns
What is situational crisis?change that results when a person faces an event or situation that causes a disruption in one’s life
What is pedagogy?science of teaching that generally refers to the teaching of children and adolescents
What is psychomotor learning?acquisition of physical skills
Name the 3 learning domainscognitive, psychomotor, and affective
Name some suggested strategies for the Cognitive DomainLecture or discussion, Panel discussion, Discovery, Audiovisual materials, Printed materials, Programmed instruction, Computer-assisted instruction programs
Name some suggested strategies for the Affective DomainRole modeling, Discussion, Panel discussion, Audiovisual materials, Role playing, Printed materials
Name some suggested strategies for the Psychomotor DomainDemonstration, Discovery, Audiovisual materials, Printed materials

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