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NUR 100 Chapter 26 Documentation Student.pdf 100% correct
- Course
- Nur 100
- Institution
- Chamberlain College Of Nursing
NUR 100 Chapter 26 Documentation S
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NUR 100 Chapter 26 DocumentationStudent
1’ A nurse preceptor is working with a student nurse’ Which behavior by the
student nurse will
require the nurse preceptor to intervene?
a’ The student nurse reads the patient's plan of care’
b’ The student nurse reviews the patient's medical record’
c’ The student nurse shares patient information with a friend’
d’ The student nurse documents medication administered to the patient’ - correct
answer ANS: C
When you are a student in a clinical setting, confidentiality and compliance with
the Health Insurance
Portability and Accountability Act (HIPAA) are part of professional practice’ When
a student nurse
shares patient information with a friend, confidentiality and HIPAA standards
have been violated,
causing the preceptor to intervene’ You can review your patients' medical records
only to seek
information needed to provide safe and effective patient care’ For example, when
you are assigned
to care for a patient, you need to review the patient's medical record and plan of
care’ You do
not share this information with classmates and you do not access the medical
records of other
patients on the unit’
,2’ A nurse exchanges information with the oncoming nurse about a patient's care’
Which action did
the nurse complete?
a’ A verbal report
b’ An electronic record entry
c’ A referral
d’ An acuity rating - correct answer ANS: A
Whether the transfer of patient information occurs through verbal reports,
electronic or written
documents, you need to follow some basic principles’ Reports are exchanges of
information among
caregivers’ A patient's electronic medical record or chart is a confidential,
permanent legal
documentation of information relevant to a patient's health care’ Nurses
document referrals
(arrangements for the services of another care provider)’ Nurses use acuity
ratings to determine the
hours of care and number of staff required for a given group of patients every
shift or every 24 hours’
3’ A nurse is auditing and monitoring patients' health records’ Which action is the
nurse taking?
a’ Determining the degree to which standards of care are met by reviewing
patients' health records
b’ Realizing that care not documented in patients' health records still qualifies as
care provided
c’ Basing reimbursement upon the diagnosis-related groups documented in
patients' records
d’ Comparing data in patients' records to determine whether a new treatment had
better outcomes than the standard treatment - correct answer ANS: A
, The auditing and monitoring of patients' health records involve nurses
periodically auditing records
to determine the degree to which standards of care are met and identifying areas
needing
improvement and staff development’ The mistakes in documentation that
commonly result in
malpractice include failing to record nursing actions; this is the aspect of legal
documentation’ The
financial billing or reimbursement purpose involves diagnosis-related groups
(DRGs) as the basis for
establishing reimbursement for patient care’ For research purposes, the
researcher compares the
patient's recorded findings to determine whether the new method was more
effective than the
standard protocol’ Data analysis contributes to evidence-based nursing practice
and quality health
care’
4’ After providing care, a nurse charts in the patient's record’ Which entry will the
nurse document?
a’ Appears restless when sitting in the chair
b’ Drank adequate amounts of water
c’ Apparently is asleep with eyes closed
d’ Skin pale and cool - correct answer ANS: D
A factual record contains descriptive, objective information about what a nurse
observes, hears,
palpates, and smells’ Objective data is obtained through direct observation and
measurement (skin
pale and cool)’ For example, "B/P 80/50, patient diaphoretic, heart rate 102 and
regular’" Avoid
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