[Solved] Worksheet

Assignment Prompt & Instructions

Instructions below

**files (4)**

– ## N315-DocuCare-Documentation-Hunt.docx

– IMG_1285.png
– IMG_1287.png
– IMG_1286.png

**## N315-DocuCare-Documentation-Hunt.docx**


**Documentation Hunt– NURS/NATB 315 Students**

| | | |
| — | — | — |
| **Overview** |
| **Estimated time to complete:** 1 hour or less<br> <br>**Target group(s)**: Nurses and nursing students<br> <br>**Brief summary of assignment:**<br>This activity is related to documentation location and standardized electronic terminology, and requires locating previous documentation of patient data. Appropriate actions you complete include finding patient data in the electronic medical record, identifying the location, noting if the location is appropriate, and, if not, identifying the appropriate location and why. |
| **Learning Objectives** |
| **At the end of this activity the learner will be able to:**<br>· Explain the relationship between documentation location and efficient access to patient data and information<br>· Describe the difference between documenting in standardized query/response lists and documenting a free text comment within electronic assessments |
| **Assignment** |
| 1. Log into thePoint and DocuCare, following all instructions given to you earlier.

2. Enter the Documentation Hunt Case.

3. Patient Name / Date of birth: ____________________________________

4. You are coming on to night shift and the day nurse is busy with another patient. While you wait for the report, you review the chart. Complete the following:

| | | |
| — | — | — |
| **Information** | **Answer.**<br>**Where did you find this?** | **Appropriate location? Where should this be documented? Why?** |
| **What percentage did the patient eat of their last meal?** | | |
| **How is the patient tolerating their diet?** | | |
| **What is the latest pain score and location?** | | |
| **What did the nurse document about the patient’s response to teaching? In other words, what does the patient need?** | | |
| **What was the amount and color of sputum today?** | | |
| **What color was the urine today?** | | |
| **What major event occurred with the patient AFTER admission and what did the nurse do?** | | |

5. Submit for review per module instructions. |

Content: E. Feldman, MS, RN / Format & Graphic: Copyright © 2015 Wolters Kluwer Health. All Rights Reserved.

## image2.JPG

## image3.png

**IMG_1285.png**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/img-1285-png-10546737)

**IMG_1287.png**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/img-1287-png-10546739)

**IMG_1286.png**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/img-1286-png-10546741)

**IMG_1286.png**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/img-1286-png-10546741)

**## N315-DocuCare-Documentation-Hunt.docx**


**Documentation Hunt– NURS/NATB 315 Students**

| | | |
| — | — | — |
| **Overview** |
| **Estimated time to complete:** 1 hour or less<br> <br>**Target group(s)**: Nurses and nursing students<br> <br>**Brief summary of assignment:**<br>This activity is related to documentation location and standardized electronic terminology, and requires locating previous documentation of patient data. Appropriate actions you complete include finding patient data in the electronic medical record, identifying the location, noting if the location is appropriate, and, if not, identifying the appropriate location and why. |
| **Learning Objectives** |
| **At the end of this activity the learner will be able to:**<br>· Explain the relationship between documentation location and efficient access to patient data and information<br>· Describe the difference between documenting in standardized query/response lists and documenting a free text comment within electronic assessments |
| **Assignment** |
| 1. Log into thePoint and DocuCare, following all instructions given to you earlier.

2. Enter the Documentation Hunt Case.

3. Patient Name / Date of birth: ____________________________________

4. You are coming on to night shift and the day nurse is busy with another patient. While you wait for the report, you review the chart. Complete the following:

| | | |
| — | — | — |
| **Information** | **Answer.**<br>**Where did you find this?** | **Appropriate location? Where should this be documented? Why?** |
| **What percentage did the patient eat of their last meal?** | | |
| **How is the patient tolerating their diet?** | | |
| **What is the latest pain score and location?** | | |
| **What did the nurse document about the patient’s response to teaching? In other words, what does the patient need?** | | |
| **What was the amount and color of sputum today?** | | |
| **What color was the urine today?** | | |
| **What major event occurred with the patient AFTER admission and what did the nurse do?** | | |

5. Submit for review per module instructions. |

Content: E. Feldman, MS, RN / Format & Graphic: Copyright © 2015 Wolters Kluwer Health. All Rights Reserved.

## image2.JPG

## image3.png

**IMG_1285.png**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/img-1285-png-10546737)

**IMG_1287.png**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/img-1287-png-10546739)

**IMG_1286.png**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/img-1286-png-10546741)

**## N315-DocuCare-Documentation-Hunt.docx**


**Documentation Hunt– NURS/NATB 315 Students**

| | | |
| — | — | — |
| **Overview** |
| **Estimated time to complete:** 1 hour or less<br> <br>**Target group(s)**: Nurses and nursing students<br> <br>**Brief summary of assignment:**<br>This activity is related to documentation location and standardized electronic terminology, and requires locating previous documentation of patient data. Appropriate actions you complete include finding patient data in the electronic medical record, identifying the location, noting if the location is appropriate, and, if not, identifying the appropriate location and why. |
| **Learning Objectives** |
| **At the end of this activity the learner will be able to:**<br>· Explain the relationship between documentation location and efficient access to patient data and information<br>· Describe the difference between documenting in standardized query/response lists and documenting a free text comment within electronic assessments |
| **Assignment** |
| 1. Log into thePoint and DocuCare, following all instructions given to you earlier.

2. Enter the Documentation Hunt Case.

3. Patient Name / Date of birth: ____________________________________

4. You are coming on to night shift and the day nurse is busy with another patient. While you wait for the report, you review the chart. Complete the following:

| | | |
| — | — | — |
| **Information** | **Answer.**<br>**Where did you find this?** | **Appropriate location? Where should this be documented? Why?** |
| **What percentage did the patient eat of their last meal?** | | |
| **How is the patient tolerating their diet?** | | |
| **What is the latest pain score and location?** | | |
| **What did the nurse document about the patient’s response to teaching? In other words, what does the patient need?** | | |
| **What was the amount and color of sputum today?** | | |
| **What color was the urine today?** | | |
| **What major event occurred with the patient AFTER admission and what did the nurse do?** | | |

5. Submit for review per module instructions. |

Content: E. Feldman, MS, RN / Format & Graphic: Copyright © 2015 Wolters Kluwer Health. All Rights Reserved.

## image2.JPG

## image3.png

**IMG_1285.png**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/img-1285-png-10546737)

**IMG_1287.png**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/img-1287-png-10546739)

**IMG_1286.png**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/img-1286-png-10546741)