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Documenting and Reporting > Fundamentals
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Documentation and Reporting
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is reviewing the documentation and reporting policies of a healthcare facility.
The nurse understands that documentation serves as a permanent record of patient information, data, and care.
Which of the following is another purpose of documentation?
A nurse is preparing to report the status of a patient to another nurse during a shift change.
The nurse should include which of the following information in the report?
(Select all that apply.).
A nurse is documenting the care provided to a patient who has a wound infection.
The nurse writes: “The wound was cleansed with normal saline and covered with a sterile dressing.
No signs of redness, swelling, or drainage were noted.” Which of the following statements reflects the nurse’s use of objective data?
A nurse is caring for a patient who has a history of depression and is taking an antidepressant medication.
The nurse asks the patient how he is feeling today.
The patient responds: “I don’t know, I guess I’m okay.” Which of the following statements by the nurse is an appropriate response?
A nurse is using a computer-based system to document the care provided to a patient who has diabetes mellitus.
The nurse enters the patient’s blood glucose level, insulin dose, dietary intake, and urine output.
The system automatically generates a graph that shows the trends and patterns of these data over time.
This type of documentation system is known as:.
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