Questions and Answers |
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Which documentation entry by the nurse is most appropriate? -
ANSWER ✔✔Patient ambulated 20 feet with unsteady gait and
required assistance.
Why is the documentation statement "patient seems depressed"
inappropriate? - ANSWER ✔✔It is subjective and not based on
objective observations.
,What is the legal significance of nursing documentation? - ANSWER
✔✔It serves as a legal record of patient care and proof that care was
provided.
A nurse forgets to chart an intervention but remembers later. What is the
correct action? - ANSWER ✔✔Document a late entry with current
date and time and indicate it is a late entry.
Which element of documentation protects patient privacy? -
ANSWER ✔✔Confidentiality
Which characteristic of documentation ensures the information reflects
exactly what occurred? - ANSWER ✔✔Accuracy
Which documentation principle requires recording care immediately after
it occurs? - ANSWER ✔✔Timeliness
Which documentation statement violates factual charting principles? -
ANSWER ✔✔Patient acting strange
Why is the 24-hour clock used in healthcare documentation? -
ANSWER ✔✔To prevent confusion between AM and PM times.
How should 9:00 PM be documented in military time? - ANSWER
✔✔2100
, Which action is considered a breach of patient confidentiality? -
ANSWER ✔✔Leaving a computer logged into a patient chart
unattended.
What is the best action to protect patient confidentiality when using
electronic records? - ANSWER ✔✔Log off the computer after
charting.
A nurse discusses a patient's diagnosis in a crowded hallway. What
principle is violated? - ANSWER ✔✔Patient confidentiality
Which patient information is considered confidential? - ANSWER
✔✔All personal and medical information about the patient.
What right does a patient have regarding their health record? -
ANSWER ✔✔The right to view and obtain copies of their health
record.
Which action is NOT permitted regarding patient medical records? -
ANSWER ✔✔Patients directly revising their records.
When are verbal orders most appropriate in clinical practice? -
ANSWER ✔✔In urgent situations when the provider cannot write the
order.
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