Electronic health record use, documentation standards, and HIPAA concepts tested on NCLEX-RN.
30 cards · basic cards · AI-written, checked twice. Edit anything.
- What does EHR stand for?
- Electronic Health Record
- What is one key purpose of nursing documentation?
- To communicate patient care information among members of the healthcare team
- What legal principle guides nursing documentation?
- If it wasn't documented, it wasn't done
- What does the SOAP note format stand for?
- Subjective, Objective, Assessment, Plan
- What does SBAR stand for?
- Situation, Background, Assessment, Recommendation
- What is SBAR primarily used for?
- Structured handoff communication between healthcare providers
- What is charting by exception?
- A documentation method where only abnormal or significant findings are recorded in detail
- What does the DAR format in focus charting stand for?
- Data, Action, Response
- What does PIE charting stand for?
- Problem, Intervention, Evaluation
- What is narrative charting?
- Documentation written as a chronological story describing patient care and events
- What type of data includes vital signs and other measurable findings?
- Objective data
- What type of data is based on what the patient reports, such as pain level?
- Subjective data
- How should a nurse label documentation written after the fact?
- As a 'late entry,' with the current date and time noted
- How should a nurse correct an error in a paper medical record?
- Draw a single line through the error, initial and date it, then write the correct entry
- What does HIPAA stand for?
- Health Insurance Portability and Accountability Act