18 Questions
What is the reason for avoiding writing the word 'error' when recording a mistake?
To prevent clients from assuming a clinical error has caused injury.
Why is it important to document what care was omitted due to client condition or refusal of treatment?
To maintain a complete and accurate record of client care.
What is the most appropriate way to end each thought when documenting client information?
With a period.
Why is it advised to follow agency protocol for computerized data entry?
To maintain the original entry visible and accessible.
What should be the focus when recording information according to the text?
Only recording information relevant to the client’s health problems and care.
Why is it essential to record all dependent and independent nursing interventions in client documentation?
To maintain a complete account of actions taken for the client.
What is the significance of avoiding restating or paraphrasing client's subjective data in documentation?
It helps maintain the accuracy of the information.
Why should nurses avoid judgments or conclusions in documentation?
To prevent bias in the recorded information.
What is the purpose of accurately documenting all data collected about a client's health status?
To provide a comprehensive view of the client's condition.
Why is it important to document date and time for each recording in client care?
To establish a chronological sequence of events.
What does recording data in a factual manner entail?
Avoiding personal interpretations and biases.
How does documenting verbatim client's subjective data contribute to effective communication with other healthcare professionals?
Ensures precise transmission of client information.
What is the main purpose of accurate and complete documentation in nursing?
To provide proof of quality care given to the client
Why is documentation usually viewed as the best evidence of what really happened to the client?
To provide an accurate account of events and care provided
What should nurses do regarding their personal password for computer records?
Keep it confidential and not share it with anyone
What should nurses do after logging on to a computer terminal?
Log off if they need to step away from the terminal
Why should nurses shred all unneeded computer-generated worksheets?
To prevent sensitive information exposure
What should IT personnel do to protect the server from unauthorized access?
Install a firewall
Learn about best practices for nursing documentation, including how to record mistakes without using the word 'error' and following the correct sequence of events. Understand the importance of appropriateness in documenting information related to clients' health problems and care.
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