Nurs 371 Exam One.docx

NURS 371 EXAM ONE 2024/2025 WITH 100% CORRECT
ANSWERS




Documentation is - correct answer The written or electronic, legal record of all pertinent interactions with the
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patient: assessing, diagnosing, planning, implementing, and evaluation
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Characteristics of effective documentation - correct answer - Consistent with professional and agency
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standards b




- Complete
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- Accurate
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- Concise
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- Factual
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- Organized
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- Timely
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- Legally prudent
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- Confidential drug
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Patient rights to documentation - correct answer - See and copy their health record
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- Update their health record
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, - Get a list of disclosures
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- Request a restriction on certain uses or disclosures
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- Choose how to receive health information
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Five rights - correct answer - Right patient
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- Right dose
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- Right route
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- Right time
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- Right drug
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- Right documentation
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- Right reason
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Documentation includes - correct answer - Client identification and demographic b b b b b b b b b




- Informed consent for treatment and procedures
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- Admission nursing history
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- Nursing diagnoses or problems
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- Nursing or multidisciplinary care plan
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- Record or nursing care treatment and evaluation
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- Medical history
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- Medical diagnoses
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- Therapy orders
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- Medical and health disciplines progress notes
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- Report of physical examinations
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- Summary of operative procedures
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- Discharge and plan of summary
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Purposes of Patient Records - correct answer - Communications with healthcare professionals
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- Record of diagnostic and therapeutic orders
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- Care planning
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