RNSG LEVEL ONE EXAM 1 correctly answered graded A+

RNSG LEVEL ONE EXAM 1Describe guidelines for effective documentation: Content - correct answer -Accurate -Well-organized (Make sure documentation reflects nursing process) -Thorough -Concise (avoid words that are unnecessary) -Objective (only the facts) -Prompt -Legible *Include the following for procedures; what was done, when, who did it, how it was done, how pt tolerated intervention, any adverse reactions Describe guidelines for effective documentation: Abbreviations - correct answer When you abbreviate, make sure it is a standard abbreviation with no possibility of having more than one meaning. Describe guidelines for effective documentation: Timing - correct answer *When documenting in an EMR, it will have a time stamp of when you are entering the information. Make sure to note the actual time if you are not charting immediately at the bedside. Try to make sure to chart immediately after giving care or nursing intervention. *If you must make a late entry because you forgot something, make sure to write "late entry" and document the time care was actually completed. This can be done up to 24 hours after. NEVER add late information without indicating that you did so.