Fundamentals of Nursing Exam 3

Purpose of Documentation

Comprehensive written account of patient care.

Written record

Serves as evidence of care provided to the patient.

Reimbursement of costs of care

Accurate documentation is crucial for justifying healthcare services.

Quality improvement

Documentation provides data for analysis and identifying areas for enhancement.

Source-Oriented Charting

Organized according to the source of information, using separate forms for different disciplines.

Problem-Oriented Medical Record Charting (POMR)

Focuses on patient status, consisting of database, problem list, plan, progress notes, and discharge summary.

SOAP Documentation

Includes Subjective, Objective, Assessment, and Plan.

Focus Charting

Directed at nursing diagnosis, patient problem, or concern, using the DAR or DAE format.

Charting by Exception

Assumes normal standards of practice are met unless otherwise documented.

Active listening

Concentration and using all senses, maintaining eye contact.

Therapeutic Communication

Focused on patient needs and promotes understanding.

Factors Affecting Communication

Include cultural differences, past experiences, and emotions.

Health Issues Related to Nutrition

Includes anorexia nervosa, bulimia, obesity, and pregnancy.

Nursing Diagnosis

Identifies potential health problems and prioritizes interventions in the nursing plan of care.

Transcultural Nursing

Nursing care that acknowledges cultural diversity and sensitivity.

Complementary Therapies

Used in conjunction with or in place of conventional medicine.

Mind-Body Interventions

Eases stress and treats chronic illnesses.

Biologic-Based Therapy

Uses natural substances such as foods and herbs for health benefits.

Nutritional Assessment

Involves history, physical exam, and lab values for evaluating dietary needs.

Omega-3 Fatty Acids

Unsaturated fats beneficial for heart health, sourced from fish and certain oils.

Cultural Competence

The ability to interact effectively with people from diverse cultural and ethnic backgrounds.