A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)
Wait until the end of the shift to document
Cover errors with correction fluid, and write in the correct information
Use as many abbreviations as possible to save space
Document objective data, leaving out opinions
The date and time should be included with each entry
Correct Answer : D,E
A. Wait until the end of the shift to document: Documentation should be done promptly after care is provided to ensure accuracy and completeness. Delaying documentation increases the risk of errors or omissions.
B. Cover errors with correction fluid, and write in the correct information: Errors should never be covered with correction fluid. Instead, a single line should be drawn through the mistake, followed by the correction and the nurse’s initials.
C. Use as many abbreviations as possible to save space: Only approved abbreviations should be used to avoid misinterpretation and increase clarity. Overuse of abbreviations can lead to confusion.
D. Document objective data, leaving out opinions: Documentation should be factual and objective (e.g., "Patient grimaced when moving" instead of "Patient appears to be in pain"). Subjective or opinion-based language should be avoided.
E. The date and time should be included with each entry: Every entry must have a date and time to provide an accurate timeline of care, ensuring legal protection and continuity of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A. Repeat the details of the prescription back to the provider: Verbal/telephone orders must be read back to ensure accuracy (known as read-back verification).
B. Record the reason for the call made to the provider and the results of the call in the Nurse’s Notes: Documentation should include:
-
Why the call was made
-
Provider’s response and order
-
Patient’s condition before and after intervention
C. Tell the charge nurse that the provider has prescribed morphine by telephone: While communication with the charge nurse is good practice, it does not replace proper documentation and verification.
D. Refuse to accept the verbal prescription because this is not an emergency: While verbal orders should be limited to emergencies, they can be accepted in certain non-emergency cases, provided read-back verification and documentation are done.
Correct Answer is A
Explanation
A. Confidentiality: The biggest concern is maintaining patient confidentiality due to risks of unauthorized access, hacking, and breaches of protected health information (PHI).
B. Adequate forms for documentation: Computerized charting typically has structured templates, ensuring that all necessary fields are included.
C. Incorrect information: While errors can occur, computerized charting often includes safeguards like drop-down menus, alerts, and validation checks to reduce mistakes.
D. None of the answers are correct: Confidentiality is a significant concern, making option A the best answer.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.