Nursing Documentation: Foundations 231

<p>Assessments, medication administration, nursing actions, treatments, and patient education</p> Signup and view all the answers

<p>Other healthcare professionals involved in the patient's care</p> Signup and view all the answers

<p>Reporting through both verbal and written communication</p> Signup and view all the answers

<p>To provide measurable, verifiable objective data</p> Signup and view all the answers

<p>Because they may mean different things to different readers</p> Signup and view all the answers

<p>By quoting the patient and describing behaviors</p> Signup and view all the answers

<p>To ensure that all problems are addressed in a timely manner</p> Signup and view all the answers

<p>To provide a complete picture of the patient's care</p> Signup and view all the answers

<p>Because the data may be outdated or inaccurate</p> Signup and view all the answers

<p>To grant formal recognition to entities that meet stated criteria</p> Signup and view all the answers

<p>To improve patient safety and quality of care</p> Signup and view all the answers

<p>Contemporaneous</p> Signup and view all the answers

<p>Subjective data is based on direct quotes, while objective data is based on observations</p> Signup and view all the answers

<p>Pt is very agitated and upset</p> Signup and view all the answers

<p>To outline the characteristics of effective documentation</p> Signup and view all the answers

<p>Protected Health Information (PHI)</p> Signup and view all the answers

<p>Leaving a computer unattended with unsecured medical records</p> Signup and view all the answers

<p>To generate complete records of clinical patient encounters</p> Signup and view all the answers

<p>Discussing in a public area</p> Signup and view all the answers

<p>First and last name</p> Signup and view all the answers

<p>Failing to log off a computer terminal</p> Signup and view all the answers

<p>To monitor fluid balance</p> Signup and view all the answers

<p>To comply with legal requirements</p> Signup and view all the answers

<p>To improve hand-off communication among healthcare professionals</p> Signup and view all the answers

<p>Fluids that enter the body, such as water, juice, and IV fluids</p> Signup and view all the answers

<p>Fluid retention, dehydration, or electrolyte imbalance may occur</p> Signup and view all the answers

<p>To provide a comprehensive record of patient care</p> Signup and view all the answers