30 Questions
What proportion of their 12-hour shift may be spent on charting by US nurses?
25-40%
Why is it essential for nurses to maintain accurate and complete documentation?
It is a legal document that protects the nurse from negligence allegations
What is the primary purpose of a patient health record?
To serve as a permanent legal document of nurse-patient interactions
What should be included in a nurse's documentation?
Assessments, medication administration, nursing actions, treatments, and patient education
Who may use the patient health record?
Other healthcare professionals involved in the patient's care
What is the nurse's role in communicating with other healthcare professionals?
Reporting through both verbal and written communication
What is the primary goal of documenting patient findings?
To provide measurable, verifiable objective data
Why should you avoid using words like 'good', 'average', or 'normal' in documentation?
Because they may mean different things to different readers
What is the recommended way to document patient behaviors?
By quoting the patient and describing behaviors
Why should you document problems as they occur in an orderly, sequential manner?
To ensure that all problems are addressed in a timely manner
What is the purpose of documenting nursing interventions and patient responses?
To provide a complete picture of the patient's care
Why should you avoid copying and pasting notes in an EHR?
Because the data may be outdated or inaccurate
What is the purpose of accrediting bodies, such as the Joint Commission, in the context of healthcare?
To grant formal recognition to entities that meet stated criteria
What is the primary purpose of collecting data in healthcare?
To improve patient safety and quality of care
What is the characteristic of effective documentation that ensures that the information is up-to-date and current?
Contemporaneous
What is the difference between subjective and objective data in healthcare documentation?
Subjective data is based on direct quotes, while objective data is based on observations
What is an example of poor documentation in healthcare?
Pt is very agitated and upset
What is the purpose of the 2010 ANA Standards for Effective Charting?
To outline the characteristics of effective documentation
What is the term for private and confidential patient information?
Protected Health Information (PHI)
What is an example of a breach in confidentiality?
Leaving a computer unattended with unsecured medical records
What is the purpose of an Electronic Health Record (EHR)?
To generate complete records of clinical patient encounters
What should you avoid doing with patient information?
Discussing in a public area
What is considered a patient/client identifier?
First and last name
What is a HIPPA violation?
Failing to log off a computer terminal
What is the primary purpose of measuring intake and output?
To monitor fluid balance
Why is it essential to maintain accurate documentation in an EHR?
To comply with legal requirements
What is the purpose of the SBAR communication tool?
To improve hand-off communication among healthcare professionals
What is included in the measurement of intake?
Fluids that enter the body, such as water, juice, and IV fluids
What is the consequence of an abnormal intake and output measurement?
Fluid retention, dehydration, or electrolyte imbalance may occur
What is the purpose of an Electronic Health Record (EHR)?
To provide a comprehensive record of patient care
Test your knowledge of effective nursing documentation, including standard professional guidelines, protecting confidential patient information, and approved abbreviations and symbols. Learn about the purposes of different types of patient health records.
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