Nur 222 Test Questions and Correct Solutions
Documentation
written, legal record of all pertinent interventions with the patient—assessments, diagnoses,
plans, interventions, and evaluations
What does documentation do?
facilitates quality, evidenced-based patient care, helps in clinical research, support decision
analysis
what are the characteristics of documentation
consistent with professional and agency standards
complete
accurate
concise
actual
organized and timely
legally prudent
confidential
Elements of documentation are:
content
timing
format
, accountability
confidentiality
Documenting times
24-hours cycle military clock is used to documents times
what is confidential
All information about patients written on paper, spoken aloud, saved on a computer
- Name, address, phone, fax, social security
- Reason person is sick
- Treatments patient receives
- Information about past health conditions
The potential breaches in patient confidentiality are
displaying information on a public screen
sending confidential e-mail messages via public networks
sharing printers among units with differing functions
discarding copies of patient information in trash cans
holding conversations that can be overheard
faxing confidential information to unauthorized persons
sending confidential messages overheard on pagers
patient Rights
See and copy their health record
Update their health record
Documentation
written, legal record of all pertinent interventions with the patient—assessments, diagnoses,
plans, interventions, and evaluations
What does documentation do?
facilitates quality, evidenced-based patient care, helps in clinical research, support decision
analysis
what are the characteristics of documentation
consistent with professional and agency standards
complete
accurate
concise
actual
organized and timely
legally prudent
confidential
Elements of documentation are:
content
timing
format
, accountability
confidentiality
Documenting times
24-hours cycle military clock is used to documents times
what is confidential
All information about patients written on paper, spoken aloud, saved on a computer
- Name, address, phone, fax, social security
- Reason person is sick
- Treatments patient receives
- Information about past health conditions
The potential breaches in patient confidentiality are
displaying information on a public screen
sending confidential e-mail messages via public networks
sharing printers among units with differing functions
discarding copies of patient information in trash cans
holding conversations that can be overheard
faxing confidential information to unauthorized persons
sending confidential messages overheard on pagers
patient Rights
See and copy their health record
Update their health record
