charting. Elevation of left forearm is the A in FOCUS charting. It describes the action or
nursing intervention. Slight hematoma on left forearm is the D referring to data in
FOCUS charting.
DIF: A REF: 391 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
11. Which of the following is evaluated as a legally appropriate notation?
1 Dr. Green made an error in the amount of medication to administer.
2 Verbalized sharp, stabbing pain along the left side of chest.
3 Nurse Williams spoke with the client about the surgery.
4 Client upset about the physical therapy.
HTTPS://BIT.LY/3EHKBMB
Entries should be concise, factual, and accurate. Verbalized sharp, stabbing pain along
the left side of chest is an example of an objective description of a clients behavior. The
nurse should not document physician made error. Instead, the nurse could chart that Dr.
Green was called to clarify order for medication administration. The nurse should chart
only for himself or herself. In this case, nurse Williams should write the charting entry.
Only objective descriptions of the clients behavior should be recorded. For example:
Client states, I dont want physical therapy! I want to go home!
DIF: A REF: 388-389 OBJ:
Comprehension TOP: Nursing Process:
This study source was downloaded by 100000857259159 from CourseHero.com on 11-18-2022 03:33:43 GMT -06:00
Evaluation
https://www.coursehero.com/file/73020880/NURS1144-Fundamentals-of-Nursing-10th-Edition-Test-BaNK-147pdf/
, MSC: NCLEX test plan designation: Safe, Effective Care Environment
12. To avoid legal risks and possible lack of confidentiality associated with
computerized documentation, many programs currently have:
1 Periodic changes in staff passwords
2 Thumbprint identification restrictions
3 All nursing staff uses the same access code
4 Only centralized medical records use the client data
HTTPS://BIT.LY/3EHKBMB
A good system of computerized documentation requires periodic changes in personal
passwords to prevent unauthorized persons form tampering with records. Many
programs do not have thumbprint identification restrictions. All nurses do not use the
same access code. Each nurse should have his or her own password. Only centralized
medical records using the client data is
This study source was downloaded by 100000857259159 from CourseHero.com on 11-18-2022 03:33:43 GMT -06:00
https://www.coursehero.com/file/73020880/NURS1144-Fundamentals-of-Nursing-10th-Edition-Test-BaNK-147pdf/
nursing intervention. Slight hematoma on left forearm is the D referring to data in
FOCUS charting.
DIF: A REF: 391 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
11. Which of the following is evaluated as a legally appropriate notation?
1 Dr. Green made an error in the amount of medication to administer.
2 Verbalized sharp, stabbing pain along the left side of chest.
3 Nurse Williams spoke with the client about the surgery.
4 Client upset about the physical therapy.
HTTPS://BIT.LY/3EHKBMB
Entries should be concise, factual, and accurate. Verbalized sharp, stabbing pain along
the left side of chest is an example of an objective description of a clients behavior. The
nurse should not document physician made error. Instead, the nurse could chart that Dr.
Green was called to clarify order for medication administration. The nurse should chart
only for himself or herself. In this case, nurse Williams should write the charting entry.
Only objective descriptions of the clients behavior should be recorded. For example:
Client states, I dont want physical therapy! I want to go home!
DIF: A REF: 388-389 OBJ:
Comprehension TOP: Nursing Process:
This study source was downloaded by 100000857259159 from CourseHero.com on 11-18-2022 03:33:43 GMT -06:00
Evaluation
https://www.coursehero.com/file/73020880/NURS1144-Fundamentals-of-Nursing-10th-Edition-Test-BaNK-147pdf/
, MSC: NCLEX test plan designation: Safe, Effective Care Environment
12. To avoid legal risks and possible lack of confidentiality associated with
computerized documentation, many programs currently have:
1 Periodic changes in staff passwords
2 Thumbprint identification restrictions
3 All nursing staff uses the same access code
4 Only centralized medical records use the client data
HTTPS://BIT.LY/3EHKBMB
A good system of computerized documentation requires periodic changes in personal
passwords to prevent unauthorized persons form tampering with records. Many
programs do not have thumbprint identification restrictions. All nurses do not use the
same access code. Each nurse should have his or her own password. Only centralized
medical records using the client data is
This study source was downloaded by 100000857259159 from CourseHero.com on 11-18-2022 03:33:43 GMT -06:00
https://www.coursehero.com/file/73020880/NURS1144-Fundamentals-of-Nursing-10th-Edition-Test-BaNK-147pdf/
