Nursing Documentation: Foundations 231
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Questions and Answers

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?

  • 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?

  • 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?

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

    Who may use the patient health record?

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

    What is the nurse's role in communicating with other healthcare professionals?

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

    What is the primary goal of documenting patient findings?

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

    Why should you avoid using words like 'good', 'average', or 'normal' in documentation?

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

    What is the recommended way to document patient behaviors?

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

    Why should you document problems as they occur in an orderly, sequential manner?

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

    What is the purpose of documenting nursing interventions and patient responses?

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

    Why should you avoid copying and pasting notes in an EHR?

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Because the data may be outdated or inaccurate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

    What is the purpose of accrediting bodies, such as the Joint Commission, in the context of healthcare?

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

    What is the primary purpose of collecting data in healthcare?

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

    What is the characteristic of effective documentation that ensures that the information is up-to-date and current?

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

    What is the difference between subjective and objective data in healthcare documentation?

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

    What is an example of poor documentation in healthcare?

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

    What is the purpose of the 2010 ANA Standards for Effective Charting?

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

    What is the term for private and confidential patient information?

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

    What is an example of a breach in confidentiality?

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

    What is the purpose of an Electronic Health Record (EHR)?

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

    What should you avoid doing with patient information?

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

    What is considered a patient/client identifier?

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

    What is a HIPPA violation?

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

    What is the primary purpose of measuring intake and output?

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

    Why is it essential to maintain accurate documentation in an EHR?

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

    What is the purpose of the SBAR communication tool?

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

    What is included in the measurement of intake?

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

    What is the consequence of an abnormal intake and output measurement?

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

    What is the purpose of an Electronic Health Record (EHR)?

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

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