NURSING DOCUMENTATION STUDY TEST 100%
SOLVED CORRECT!
Nursing Documentation
any information written, printed, or electronically entered into a patient's health care record.
Quality documentation and reporting have six characteristics
factual, accurate, complete, current, organized, and confidential
you should question medication orders when:
-unusually large or small dosage
-route of administration other then the recommended route
-the order seems incorrect or inappropriate for the patient
-hand written order illegable
when to withold medication
-right dose
-right patient
-right toute
-right time
-right documentation
-right meds
TO
VO
, telephone order
verbal order
Documenting Medication Administration
-name of drug
-dosage
-route of administration and injection site
-time
PNR medication
indication and therapeutic response
witheld medication
time, reason, and additional action taken
Do not use trailing zero
2 mg not 2.0 mg
do use preceding zeros
0.5
he nurse is called to another patient's room before having the opportunity to document a
medication given to a patient. Which action should the nurse take?
Document the medication administration without delay and, if necessary, have another nurse
assist the other patient.
SOLVED CORRECT!
Nursing Documentation
any information written, printed, or electronically entered into a patient's health care record.
Quality documentation and reporting have six characteristics
factual, accurate, complete, current, organized, and confidential
you should question medication orders when:
-unusually large or small dosage
-route of administration other then the recommended route
-the order seems incorrect or inappropriate for the patient
-hand written order illegable
when to withold medication
-right dose
-right patient
-right toute
-right time
-right documentation
-right meds
TO
VO
, telephone order
verbal order
Documenting Medication Administration
-name of drug
-dosage
-route of administration and injection site
-time
PNR medication
indication and therapeutic response
witheld medication
time, reason, and additional action taken
Do not use trailing zero
2 mg not 2.0 mg
do use preceding zeros
0.5
he nurse is called to another patient's room before having the opportunity to document a
medication given to a patient. Which action should the nurse take?
Document the medication administration without delay and, if necessary, have another nurse
assist the other patient.
