NUR1400 Exam 2 Documentation Questions With Complete
Solutions
- accurate, up to date and complete
- quick and efficient
- secure sharing
- more effective diagnosis, reduced error and safer care
- legible, complete, streamlined documentation
- cost saving
- favorable outcomes more ofter Correct Answers What are the
advantages to electronic records?
- admission, shift assessment
- care plan
- work list
- notes
- flow sheets
- results review
- medication administration record
- discharge and transfer summaries Correct Answers Patient
records include:
- Change-of-shift report of handoff report
- transfer
- discharge
- telephone reports (labs, imaging, providers)
- Reports to family members and significant others Correct
Answers When does reporting occur?
- data
- action
, - response Correct Answers Focus charting; DAR
- document pertinent health or medication information
(allergies)
- document nursing activities (hourly vital signs)
- document administered medication
- write in legible handwriting
- complete records (an assessment sheet)
- document medication interactions or changes in a patient's
condition Correct Answers The most common charting
mistakes in malpractice are failure to:
- identity/introduction
- situation
- background
- assessment
- recommendation/ request
- questions Correct Answers What is ISBARQ?
- If the patient is unable to communicate information
- Information should be shared in a manner that is honest,
compassionate, and respectful of the person's ability to
understand medical concepts Correct Answers When can a
nurse give report to family members and significant others?
- inconsistencies and time gaps will create a presumption of
negligence
- conversely, careful and complete missing and medical records
will often play a significant part in the dismissal of a patient's
claim of malpractice
Solutions
- accurate, up to date and complete
- quick and efficient
- secure sharing
- more effective diagnosis, reduced error and safer care
- legible, complete, streamlined documentation
- cost saving
- favorable outcomes more ofter Correct Answers What are the
advantages to electronic records?
- admission, shift assessment
- care plan
- work list
- notes
- flow sheets
- results review
- medication administration record
- discharge and transfer summaries Correct Answers Patient
records include:
- Change-of-shift report of handoff report
- transfer
- discharge
- telephone reports (labs, imaging, providers)
- Reports to family members and significant others Correct
Answers When does reporting occur?
- data
- action
, - response Correct Answers Focus charting; DAR
- document pertinent health or medication information
(allergies)
- document nursing activities (hourly vital signs)
- document administered medication
- write in legible handwriting
- complete records (an assessment sheet)
- document medication interactions or changes in a patient's
condition Correct Answers The most common charting
mistakes in malpractice are failure to:
- identity/introduction
- situation
- background
- assessment
- recommendation/ request
- questions Correct Answers What is ISBARQ?
- If the patient is unable to communicate information
- Information should be shared in a manner that is honest,
compassionate, and respectful of the person's ability to
understand medical concepts Correct Answers When can a
nurse give report to family members and significant others?
- inconsistencies and time gaps will create a presumption of
negligence
- conversely, careful and complete missing and medical records
will often play a significant part in the dismissal of a patient's
claim of malpractice
