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Questions and Answers
What is a record in nursing?
What is a record in nursing?
- A formal, legal document that provides evidence of a client’s care and can be written or computer based. (correct)
- A document that is not considered important in the nursing profession
- A document that is not required by law
- An informal document with no legal significance
Which method of documentation includes problem-oriented medical records, PIE charting, and charting by exception?
Which method of documentation includes problem-oriented medical records, PIE charting, and charting by exception?
- Problem-oriented medical records (correct)
- Charting by exception
- Source-oriented medical records
- PIE charting
What is the consequence if something is done but not written in nursing documentation?
What is the consequence if something is done but not written in nursing documentation?
- It will not matter in the nursing profession
- It will be considered as done
- It will be considered as not done (correct)
- It will not affect the client's care
What is the purpose of client records in nursing?
What is the purpose of client records in nursing?
What should nurses use to document steps of the nursing process (assessing, diagnosing, planning, implementing, and evaluating)?
What should nurses use to document steps of the nursing process (assessing, diagnosing, planning, implementing, and evaluating)?
What should nurses identify when it comes to clinical documentation?
What should nurses identify when it comes to clinical documentation?
What is the process of making an entry on a client record called?
What is the process of making an entry on a client record called?
According to the American Nurses Association Code of Ethics, what duty does the nurse have regarding patient information?
According to the American Nurses Association Code of Ethics, what duty does the nurse have regarding patient information?
What does the HIPAA refer to?
What does the HIPAA refer to?
What is the rightful owner of the client's record according to the text?
What is the rightful owner of the client's record according to the text?
What should be avoided in documentation, according to the legal guidelines presented?
What should be avoided in documentation, according to the legal guidelines presented?
What is the correct action regarding errors in documentation?
What is the correct action regarding errors in documentation?
When carrying out an order that is written incorrectly, what should be documented according to the text?
When carrying out an order that is written incorrectly, what should be documented according to the text?
What does the text state about documenting discussions with providers initiated to seek order clarification?
What does the text state about documenting discussions with providers initiated to seek order clarification?
Who is accountable for the information entered on the patient's record?
Who is accountable for the information entered on the patient's record?
What is restricted access to the client's record limited to?
What is restricted access to the client's record limited to?
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