Answers
Are charts a legal document? - ANSWER-Yes
What is your best legal device if you are in a malpractice suit? - ANSWER-the chart
Can you put late entries into the charting system? - ANSWER-Yes
What three steps should charting follow? - ANSWER-Assessment, Intervene, Evaluate
What happens if you do not chart the information? - ANSWER-it technically never
happened
What is the mobile computer system called in the hospital? What did it used to be
called? What do they mean? - ANSWER-WOW- workstation on wheels
used to be called COW- computer on wheels
In charting, should you record your findings or your interpretation of what is going on? -
ANSWER-your findings
What words should be avoided when charting? - ANSWER-good, average, normal,
sufficient, adequate
Should you record precautions or preventive measures you have used? - ANSWER-yes
, What along with your name should be included when charting? - ANSWER-date and
time
In nursing, what time and measurement system do we use? - ANSWER-military time
and metric system
Should you document before doing the task? - ANSWER-NO
How are errors corrected in charting? - ANSWER-a single line through the word with
error in charting written beside or above along with your signature
Who can give verbal orders? - ANSWER-An RN
What is paralanguage? - ANSWER-the tone, pitch, speed, pace, volume, and inflection
of the voice in addition to the words being said
What is nonverbal language? - ANSWER-touch, eye contract, facial expression,
posture, gait, gestures, general physical appearance, mode of dress, grooming, sounds,
and silence
What is professionalism? - ANSWER-The assimilation of nursing skills and knowledge
integrated with dignity and respect for all human beings, incorporating the assumptions
and values of the profession while maintaining accountability and self-awareness
What is accountability? - ANSWER-To be answerable to oneself and others for one's
own choices, decisions and actions as measured against a standard such as that
established by the Code of Ethics for Nurses with Interpretive Statements
What is patient privacy? - ANSWER-includes body and treatment