Podcast
Questions and Answers
What proportion of their 12-hour shift may be spent on charting by US nurses?
What proportion of their 12-hour shift may be spent on charting by US nurses?
- 25-40% (correct)
- 50-60%
- 10-20%
- 40-50%
Why is it essential for nurses to maintain accurate and complete documentation?
Why is it essential for nurses to maintain accurate and complete documentation?
- It is a requirement for hospital accreditation
- It helps in billing and insurance purposes
- It serves as a communication tool among healthcare professionals
- It is a legal document that protects the nurse from negligence allegations (correct)
What is the primary purpose of a patient health record?
What is the primary purpose of a patient health record?
- To facilitate medication administration
- To track patient progress
- To communicate with other healthcare professionals
- To serve as a permanent legal document of nurse-patient interactions (correct)
What should be included in a nurse's documentation?
What should be included in a nurse's documentation?
Who may use the patient health record?
Who may use the patient health record?
What is the nurse's role in communicating with other healthcare professionals?
What is the nurse's role in communicating with other healthcare professionals?
What is the primary goal of documenting patient findings?
What is the primary goal of documenting patient findings?
Why should you avoid using words like 'good', 'average', or 'normal' in documentation?
Why should you avoid using words like 'good', 'average', or 'normal' in documentation?
What is the recommended way to document patient behaviors?
What is the recommended way to document patient behaviors?
Why should you document problems as they occur in an orderly, sequential manner?
Why should you document problems as they occur in an orderly, sequential manner?
What is the purpose of documenting nursing interventions and patient responses?
What is the purpose of documenting nursing interventions and patient responses?
Why should you avoid copying and pasting notes in an EHR?
Why should you avoid copying and pasting notes in an EHR?
What is the purpose of accrediting bodies, such as the Joint Commission, in the context of healthcare?
What is the purpose of accrediting bodies, such as the Joint Commission, in the context of healthcare?
What is the primary purpose of collecting data in healthcare?
What is the primary purpose of collecting data in healthcare?
What is the characteristic of effective documentation that ensures that the information is up-to-date and current?
What is the characteristic of effective documentation that ensures that the information is up-to-date and current?
What is the difference between subjective and objective data in healthcare documentation?
What is the difference between subjective and objective data in healthcare documentation?
What is an example of poor documentation in healthcare?
What is an example of poor documentation in healthcare?
What is the purpose of the 2010 ANA Standards for Effective Charting?
What is the purpose of the 2010 ANA Standards for Effective Charting?
What is the term for private and confidential patient information?
What is the term for private and confidential patient information?
What is an example of a breach in confidentiality?
What is an example of a breach in confidentiality?
What is the purpose of an Electronic Health Record (EHR)?
What is the purpose of an Electronic Health Record (EHR)?
What should you avoid doing with patient information?
What should you avoid doing with patient information?
What is considered a patient/client identifier?
What is considered a patient/client identifier?
What is a HIPPA violation?
What is a HIPPA violation?
What is the primary purpose of measuring intake and output?
What is the primary purpose of measuring intake and output?
Why is it essential to maintain accurate documentation in an EHR?
Why is it essential to maintain accurate documentation in an EHR?
What is the purpose of the SBAR communication tool?
What is the purpose of the SBAR communication tool?
What is included in the measurement of intake?
What is included in the measurement of intake?
What is the consequence of an abnormal intake and output measurement?
What is the consequence of an abnormal intake and output measurement?
What is the purpose of an Electronic Health Record (EHR)?
What is the purpose of an Electronic Health Record (EHR)?
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