Nursing Documentation Best Practices
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Questions and Answers

What is the reason for avoiding writing the word 'error' when recording a mistake?

  • To ensure all assessments are accurately documented.
  • To make the recording process faster and more efficient.
  • To avoid using correction fluid in documentation.
  • To prevent clients from assuming a clinical error has caused injury. (correct)

    • Why is it important to document what care was omitted due to client condition or refusal of treatment?

  • To protect the nurse from liability.
  • To maintain a complete and accurate record of client care. (correct)
  • To ensure accurate billing for services provided.
  • To inform the client about the omissions.

    • What is the most appropriate way to end each thought when documenting client information?

  • With a question mark.
  • With a comma.
  • With an exclamation point.
  • With a period. (correct)

    • Why is it advised to follow agency protocol for computerized data entry?

    <p>To maintain the original entry visible and accessible.</p> Signup and view all the answers

    What should be the focus when recording information according to the text?

    <p>Only recording information relevant to the client’s health problems and care.</p> Signup and view all the answers

    Why is it essential to record all dependent and independent nursing interventions in client documentation?

    <p>To maintain a complete account of actions taken for the client.</p> Signup and view all the answers

    What is the significance of avoiding restating or paraphrasing client's subjective data in documentation?

    <p>It helps maintain the accuracy of the information.</p> Signup and view all the answers

    Why should nurses avoid judgments or conclusions in documentation?

    <p>To prevent bias in the recorded information.</p> Signup and view all the answers

    What is the purpose of accurately documenting all data collected about a client's health status?

    <p>To provide a comprehensive view of the client's condition.</p> Signup and view all the answers

    Why is it important to document date and time for each recording in client care?

    <p>To establish a chronological sequence of events.</p> Signup and view all the answers

    What does recording data in a factual manner entail?

    <p>Avoiding personal interpretations and biases.</p> Signup and view all the answers

    How does documenting verbatim client's subjective data contribute to effective communication with other healthcare professionals?

    <p>Ensures precise transmission of client information.</p> Signup and view all the answers

    What is the main purpose of accurate and complete documentation in nursing?

    <p>To provide proof of quality care given to the client</p> Signup and view all the answers

    Why is documentation usually viewed as the best evidence of what really happened to the client?

    <p>To provide an accurate account of events and care provided</p> Signup and view all the answers

    What should nurses do regarding their personal password for computer records?

    <p>Keep it confidential and not share it with anyone</p> Signup and view all the answers

    What should nurses do after logging on to a computer terminal?

    <p>Log off if they need to step away from the terminal</p> Signup and view all the answers

    Why should nurses shred all unneeded computer-generated worksheets?

    <p>To prevent sensitive information exposure</p> Signup and view all the answers

    What should IT personnel do to protect the server from unauthorized access?

    <p>Install a firewall</p> Signup and view all the answers

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