Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:
patient's nursing problem
interventions carried out to meet the patient's needs
patient's medical problem
the patient's response to the intervention carried out
The Correct Answer is B
A. Patient's nursing problem: Nursing problems are identified in assessments, not the actual care documentation.
B. Interventions carried out to meet the patient’s needs: Documentation should include interventions, the time they were performed, and the caregiver’s signature for legal and professional accountability.
C. Patient’s medical problem: Medical problems are diagnosed by physicians, while nurses document care interventions related to nursing diagnoses.
D. The patient's response to the intervention carried out: While patient responses should be documented, this question focuses on recording interventions, not patient reactions.
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Related Questions
Correct Answer is C
Explanation
A. The care plan: While important for care, the care plan alone does not provide a full picture of patient care over time.
B. The medical orders: Medical orders show physician instructions but do not capture the full scope of patient care.
C. The entire record: The entire medical record can be subpoenaed and used as legal evidence, including notes, orders, test results, and nursing documentation.
D. Nursing notes: Nursing notes are part of the medical record but do not represent the full legal documentation on their own.
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.
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