NURS 1117 Unit 3

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  1. Documentation
    the written or typed legal record of  all pertinent  interactions with the patient-assessing, diagnosing, implementing, and evaluating.
  2. Documentation should be:
    complete, accurate, concise, factual, organized, and timely, legally prudent, and confidential.
  3. ANA
    American Nursing Association
  4. What are some examples of patient confidentiality breeches?
    speaking over the phone to a supposed spouse.
  5. What is the purpose of progress notes?
    to inform the caregivers of the progress a patient is making toward achieving expected outcomes
  6. What methods are used to record the patients progress?
    PIE and SOAP 
  7. What does SOAP stand for?
    • Subjective
    • Objective
    • Assessment 
    • Plan
  8. What does PIE stand for?
    • Problem
    • Intervention 
    • Evaluation
  9. What does a collaborative pathway do?
    It specifies the plan of care linked to expected outcomes along a timeline
  10. Name six types of nursing documentation
    • 1.  Baseline nursing assessment 
    • 2. Plan of care
    • 3.  Progress notes
    • 4.  Flow sheets
    • 5.  Discharge and Transfer
    • 6.  Home-Health & long-term care documentation
  11. What does HIPAA stand for?
    • Health
    • Insurance 
    • Portability 
    • Act
  12. What does JACHO stand for and what do they do?
    Joint Commission on Accreditation of Healthcare Organizations:

    Integrates use of outcomes and performance measures into accreditation process (national patient safety goals)
  13. What is NCQA and what do they do?
    • National Committee for Quality Assurance:
    • Targets these areas; effectiveness of care, access & availability of care, patient satisfaction, health plan stability, use of services, costs, and health plan descriptive information
  14. What does PHI stand for?
    • Patient
    • Health 
    • Information
Card Set
NURS 1117 Unit 3
Nursing 1117 Unit #3 Collaborative Concepts
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