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