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LVN UNITEK QUIZ #3 WITH
COMPLETE SOLUTION
Question :What are the purposes of patient charts?
Correct answer:1. documented communication
2.permanent record for accountability
- legal record of care
- teaching
- research and data collection
Question :What do patient charts provide?
Correct answer:Concise, accurate, and permanent record
of past and current medical and nursing problems, plans for care, care given, and the patient's responses to various treatments of care
Question :What is focus charting?
Correct answer:modified list of patient problem
statements that are used as an index for nursing documentation.
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uses the nursing process and the more positive concept of the patients needs rather than medical diagnoses and problems
Question :POMR
Correct answer:Problem Oriented Medical Record
Question :What is POMR charting?
Correct answer:organized according to scientific problem
solving system or method.The principal sections are database, problem list, care plan, and progress notes
Question :What is DARE used for?
Correct answer:focus charting (Data, Action, Response,
Education)
Question :Why are outside agencies in Long Term
healthcare documentation important?
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Correct answer:play an instrumental role in determining
standards and policies for documentation
Question :What is OBRA?
Correct answer:Omnibus Budget Reconciliation Act of
1987 instituted significant Medicare and Medicaid requirements for long-term care provision and documentation.Are minimum data sets and regulated standards for resident assessments, individualized care plans, and qualifications for health care providers
Question :Why is confidentiality important in patient
records?
Correct answer:The Health Insurance Portability and
Accountability Act (HIPAA) affords certain protections to persons covered by health care plans, including continuity of coverage when changing jobs, standards for electronic health care transactions, and primary safeguards for the privacy of individually identifiable patient information
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Question :What is the implementation of the nursing
process by the RN and LVN?Correct answer:-ASSESS: RN is responsible for initial assessment while LVN assists with ongoing assessments
-DIAGNOSIS: RN identifies appropriate nursing
diagnosis (patient problem) with assistance from LVN
-PLAN/OUTCOME IDENTIFIED: RN develops
goals/expected outcomes directly associated with nursing diagnosis and LVN can also help identify these
-IMPLEMENT: RN and LVN implement proposed plan
-EVALUATE: RN and LVN perform ongoing
assessments and RN determines whether needs/goals have been met
Question :What is the differentiation of medical and
patient problems?
Correct answer:patient problem statements address human
responses to health problems and life processes