NCM 103 Fundamentals in Nursing: Documenting and Reporting

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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?

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?

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?

To provide evidence of the client’s care and treatment Signup and view all the answers

What should nurses use to document steps of the nursing process (assessing, diagnosing, planning, implementing, and evaluating)?

Various forms in the client record such as Kardexes, flow sheets, progress notes, discharge/transfer forms Signup and view all the answers

What should nurses identify when it comes to clinical documentation?

Prohibited abbreviations, acronyms, and symbols that cannot be used in any form of clinical documentation Signup and view all the answers

What is the process of making an entry on a client record called?

Charting Signup and view all the answers

According to the American Nurses Association Code of Ethics, what duty does the nurse have regarding patient information?

To maintain confidentiality of all patient information Signup and view all the answers

What does the HIPAA refer to?

Health Insurance Portability and Accountability Act of 1996 Signup and view all the answers

What is the rightful owner of the client's record according to the text?

The institution or agency Signup and view all the answers

What should be avoided in documentation, according to the legal guidelines presented?

Retaliatory or critical comments about a patient or care provided by another healthcare professional Signup and view all the answers

What is the correct action regarding errors in documentation?

Correct all errors promptly Signup and view all the answers

When carrying out an order that is written incorrectly, what should be documented according to the text?

"Dr. Smith was called to clarify order for analgesic" Signup and view all the answers

What does the text state about documenting discussions with providers initiated to seek order clarification?

"Document discussions with date, time, and outcome" Signup and view all the answers

Who is accountable for the information entered on the patient's record?

"Do not document for someone else" Signup and view all the answers

What is restricted access to the client's record limited to?

Health professionals involved in giving care to the client. Signup and view all the answers

NCM 103 Fundamentals in Nursing: Documenting and Reporting

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