3-2-1 Code It
6th Edition
ISBN: 9781337660549
Author: GREEN
Publisher: Cengage
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The elec
of
4. Identify the components of a clinical record.
A. Individual Patient File Folder
Components of the clinical record are organized and
B. Treatment Plan Form
7. WI
a.
placed inside.
C. Telephone Information Form
b.
Provides demographic and financial information.
Documents probing, bleeding, mobility, and furcation
D. Signature on File Form
C.
conditions.
E. Registration Form
d.
reasonable results, and alerts the patient to complications that
may result.
Outlines the work that is going to be done, describes
F. Recall Examination Form
- G. Progress Notes Form
e.
Estimated cost of dental treatment and payment
8.
H. Problem/Priority List
schedule.
I. Periodontal Screening Examination Form
f.
Necessary to document the medical needs as well as
the dental needs of the patient.
Used to update and record conditions at the time of
J. Medical History Form
K. Financial Arrangements Form
each recall visit.
h.
Records treatment.
L. Dental Radiographs
Prioritizes treatment that needs to…
1. Identify seven pieces of information that should be maintained in a log regarding preauthorizataion, precertification, or referral procedures for various insurance carriers. Explain why each is important.
2. Your supervisor has given you a number of rejected claims and asks you to determine why the claims were denied and to maintain a log of these reasons to be discussed at the next team meeting. How will you proceed with this assignment?
A nurse makes a medication error. The best action is to:
a. Do not document any error on the patient's record. Document only on the incident or quality assurance report.
b. Document in the patient's record the error by either noting the omission of a drug or adding the drug given if it does not appear on the medication record
c. Document in the patient's record the error by either noting the omission of a drug or adding the drug as given even if it does not appear on the medication record describe the circumstances surrounding the error.
d. Document in the patient's record the error by either noting the omission of a drug or adding the drug as given if it does not appear on the MAR; also document on the incident or quality assurance report .
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Need a deep-dive on the concept behind this application? Look no further. Learn more about this topic, biology and related others by exploring similar questions and additional content below.Similar questions
- In a paper of 500-750 words, clearly identify the clinical problem and how it can result in a positive patient outcome. Step 1: Create PICOT question; A PICOT question is presented and provides a clear framework for the capstone project change proposal. Your PICOT question should clearly outline all of these elements: patient, intervention, comparison, outcome and time. Step 2: PICOT Problem: Identify the PICOT problem, what clinical problems or issues may arise from clinical care? The PICOT problem as it relates to evidence-based solution, nursing intervention, patient care, health care agency, and nursing practice is thoroughly described. Step 3: Describe nursing intervention: A nursing intervention used to address the problem. Compare the nursing intervention to a patient population not currently receiving the nursing intervention, and timeframe needed to implement the change process. Step 4: Summarize Clinical Problem and Patient Outcome: The clinical problem and how it can result…arrow_forwardCase Scenario: You are assigned to care to a client confined in the pediatric intensive care unit. The client has an order for insertion of NG tube. After insertion you are going to document the procedure: 1. What assessment would be observed from the patient? 2. Create an FDAR charting for this patient. DATE/ TIME FOcus DATA, ACTION and RESPONSE After two weeks, the client's NGT was ordered to be removed. Make an FDAR on the removal of the NGT procedure. DATA, ACTION and RESPONSE DATE/ TIME FOCUSarrow_forwardNCLEX practice: A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming: A. Fresh, green vegetables B. Bananas and oranges C. Lean red meat D. Creamed cornarrow_forward
- A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse to help the client take the medication? a. In most settings, student nurses are permitted to accept verbal orders from a physician. b. Upon admittance to a hospital, all patient medications from home should be sent home with the family or placed in safe-keeping. c. When a patient is admitted to a hospital, all drugs that the physician may have ordered while the patient was at home are continued. d. Safe practice dictates that a nurse follows. Written or verbal orders.arrow_forward1. What is the least component of the documentation system? a. Admission assessment b. Problem list c. Care plan or critical pathway d. Flow sheets 2. What contains a complete patient profile and history? a. Admission assessment b. Problem list c. Care plan or critical pathway d. Flow sheets 3. Where do list of actual and potential health problems appear? a. Admission assessment b. Problem list c. Care plan or critical pathway d. Flow sheets 4. What is individualized care plan for each patient mean? a. Admission assessment b. Problem list c. Care plan or critical pathway d. Bed sheets 5. Where do you find the list of observations? a. Check list b. Problem list c. Flow sheets d. Bed sheets 6. What do you call the summary or report written at the time of patient discharge or transfer? a. Check summary b. Discharge summary c. Billing statement d. None of the abovearrow_forwarddiscuss and justify 2 nursing safety considerations for patients receiving preoperative medication while awaiting transfer to surgeryarrow_forward
- Please explain in your own words your understanding of the NSQHS Medication Safety Standard. Please provide a detailed example from your clinical placements of this standard to your practice (the example must be presented using the STAR format).arrow_forwardNeed slides see instructions too. The objective of this is to create a PowerPoint presentation focusing on a quality initiative in nursing. Quality Concepts to Choose From: 1. Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury 2. Catheter Associated Urinary Tract Infection (CAUTI) 3. Residents Experiencing One or More Falls with Major Injury 4. Clostridium difficile Infection (CDI) 5. Potentially Preventable 30-Day Post-Discharge Readmission 6. Pressure Ulcers That Are New or Worsened 7. Change in Self-Care for Medical Rehabilitation Patients 8. Change in Mobility Score for Medical Rehabilitation Patients • Presentation Requirements: • The presentation should consist of 7-10 slides (excluding the title slide and references). • Use evidence-based resources to explain the chosen clinical problem/quality initiative. • Slides should be engaging, minimally cluttered, and free from spelling errors. • Each presentation should address the following: •…arrow_forward
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