Professional Communication Documentation And Informatics

Question 1

Documentation

Answer 1

Anything written or printed on which you rely as record or proof of patient actions and activities

Question 2

Guidelines for quality documentation and reporting

Answer 2

Factual 
Accurate
Complete
Current 
Organized 
-signature

Question 3

SOAP

Answer 3

Subjective data
Objective data
Assessment
Plan

Question 4

SOAP IE

Answer 4

Subjective data
Objective data
Assessment
Plan
Intervention 
Evaluation

Question 5

PIE

Answer 5

Problem
Intervention
Evaluation

Question 6

DAR

Answer 6

Data(both objective and subjective)
Action or nursing intervention
Response for the patient

Question 7

Legal documentation

Answer 7

Accurate documentation is one of the best defenses for legal claims associated with nursing care

Question 8

SBAR

Answer 8

Situation
Background
Assessment
Recommendation