12-18 per minute
Traditional Charting, Problem-Oriented Medical Record (POMR), Focus Charting Format and Charting by Exception
Criminal and Civil
Defamation
1996
Signs
60-100 per minute
Listening
The physician or institution
Slander
Assertive, Unassertive and Aggressive
Actual, Risk, Syndrome and Wellness
The Joint Commision (TJC)
Assess, Diagnose, Plan and Identify Outcomes, Implement and Evaluate
Nursing Notes
Libel
Data Clustering
Temperature, Pulse, Respirations, BP and Pain Level
The actual beating of the heart
Symptoms
Criminal
Alternative Methods of Communication
The Personal Zone
Nonverbal
Ear
What is another term for subjective data
In what year did Congress pass The Health Insurance Portability and Accountability Act (HIPAA)
Which accreditation agency specifies guidelines for documentation
18 inches to 4 feet away from a person comprises what zone
When performing an assessment, grouping related cues together is called
The form on the chart where the nurse records their observations, care given and patient's responses
What are the 2 basic categories of law
Methods of Recording Data
Which type of law affects society in general or as a whole
What is the normal/average rate of respiration for an older adult
Who owns the original copy of a patient's medical record
What is another term for objective data
Vital signs include what
What is one of the most difficult therapeutic communication skill to master
A malicious or untrue writing about a person brought to other's attention
What is the normal/average pulse rate for an adult
What does the apical pulse represent
Voice, Eye Contact, Physical Appearance, Gestures and Posture are types of what kind of communication
What are the 5 steps involved in the nursing process
What are the 4 main types of nursing diagnoses
When taking a temperature with a tympanic thermometer, where would it be placed
Lip Reading, Sign Language, Word or Picture Cards and Communication Boards are all examples of what
What are the 3 styles or types of communication
Spoken or written statements made maliciously and on purpose that may injure a person's reputation
Malicious or untrue spoken words about another person
