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Fundamentals Ch. 17-20

Across
The ANA states that the most important purpose of the client record is _____________ within the health care team.
Which documentation note allows the nurse the ability to address routine care and record patient problems in the nurse's own words?
Identifying criteria and standards, collecting date, interpreting and summarizing findings, documenting your judgment, terminating, continuing or modifying the plan are the five classic elements of ?
The shorthand documentation method that makes use of well-defined standards of practice and is least likely to standing up in court is known as ?
The step of the nursing process where evidence based nursing actions planned in the previous step are carried out?
All documentation should have a date and _________ the care was done.
The __________ is always the nurses's primary concern?
Displaying information on a computer screen that is viewed by unauthorized users is a ___________ in patient confidentiality.
Each nursing intervention should be supported by?
Admission protocols of OBGYN patients, bowel programs that allow the nurse to select and administer necessary bowel intervention are called?
_______ information about patients is considered private or confidential, whether written on paper, saved on a computer, or spoken aloud.
Focus on systems and processes, Focus on patients, Focus on being part of the team, focus on use of the data are key principles of quality improvement identified by?
The nurse writes an outcome for a patient who is trying to lose weight "the patient values a healthy lifestyle and healthy weight", this is an example of what type of outcome?
Appropriate ___________ sharing or charting of information will improve decision making, avoid re-admissions, and will assist in avoiding errors.
Down
Include nursing actions aimed at management of the patient care environment would be known as what type of care intervention?
The hospital you are working at is implementing a new EHR system and has employed experts to conduct classes for using the EHR system, what phase is this?
any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes, this is what type of intervention?
The nurse is testing a new computer program designed to store patient date, in what phase of testing would the nurse determine if the system can handle high volumes of end user or care providers using the system at the same time?
The two part statement that includes a decision about how well the outcome was met along with patient data or behaviors that support this decision is known as?
Measurable qualities, attributes, or characteristics, that identify skill, knowledge or health status?
After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "we're doing well, but we can do better! Who's got an idea to foster increased patient well-being and satisfaction?" This is an example of leadership that values?
Collaborative pathways are also called?
Nursing documentation should be charted?
What is the only permanent legal document that details the nurse's interactions with the patient?
Identifying the patient or nurse variables responsible for inaccuracy are part of the nursing response identified in common problems noted during evaluation of what part of the nursing process?
The nurse is caring for a client in a long term care facility, the client has become dehydrated, the client admits to the nurse that she cannot stand the thought of drinking the water from the kitchen, the nurse should respond by modifying which resource? A. Personnel B. Equipment C. Visitors D. Environment
The nurse documents the following outcome "the patient is able to explain the relationship between diet and increased blood glucose", this is an example of what type of outcome?
Patient concerns and behaviors, therapies and responses, changes of condition, and significant events such as teaching etc. may appear in what type of charting?
What type of care intervention would include both psychosocial and physiologic actions.
The patient reports feeling nauseated, what part of the SOAP acronym would this fall under?