Author Question: Review the charting sample and determine which documentation error occurred. 1000: Hygienic care ... (Read 18 times)

colton

  • Hero Member
  • *****
  • Posts: 627
Review the charting sample and determine which documentation error occurred.
 
  1000: Hygienic care given
  1100: Complaint of leg pain
  1300: Appetite good, resting comfortably
 
  a. Recording on the wrong chart
  b. Failure to document an intervention
  c. Failure to document a discontinued medication
  d. Failure to record outcome of an intervention

Question 2

A client is 3 days postoperative from gallbladder surgery secondary to gallstones. Domain: Physiological. Class: Fluid and electrolyte balance. Activity:
 
  Check intravenous fluid rate intake every hour. Which of the following nursing coding systems is represented in this situation?
 
  a. North American Nursing Diagnosis (NANDA)
  b. Nursing intervention classification
  c. Nursing outcome classification
  d. Omaha system of client problems



SamMuagrove

  • Sr. Member
  • ****
  • Posts: 312
Answer to Question 1

ANS: B
The nurse failed to document an intervention for the client's complaint of leg pain. The interventions are actions that nurses perform in settings relevant to illness prevention, illness treatment, and health promotion. There is no evidence the nurse has recorded on the wrong chart. There is no evidence the nurse has failed to document a discontinued medication. The nurse has recorded the outcome of an intervention by stating the client has a good appetite and is resting comfortably.

Answer to Question 2

ANS: B
The nursing intervention classification identifies nursing interventions that are classified under domains and classes. NANDA is a classification of nursing diagnoses. Nursing outcome classification identifies and classifies nursing-sensitive outcomes of client care. The Omaha system classifies problems under four levels: (1) major domains, (2) specific problems, (3) modifiers, and (4) signs and symptoms.



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question


 

Did you know?

The Food and Drug Administration has approved Risperdal, an adult antipsychotic drug, for the symptomatic treatment of irritability in children and adolescents with autism. The approval is the first for the use of a drug to treat behaviors associated with autism in children. These behaviors are included under the general heading of irritability and include aggression, deliberate self-injury, and temper tantrums.

Did you know?

According to the FDA, adverse drug events harmed or killed approximately 1,200,000 people in the United States in the year 2015.

Did you know?

Medications that are definitely not safe to take when breastfeeding include radioactive drugs, antimetabolites, some cancer (chemotherapy) agents, bromocriptine, ergotamine, methotrexate, and cyclosporine.

Did you know?

Astigmatism is the most common vision problem. It may accompany nearsightedness or farsightedness. It is usually caused by an irregularly shaped cornea, but sometimes it is the result of an irregularly shaped lens. Either type can be corrected by eyeglasses, contact lenses, or refractive surgery.

Did you know?

As many as 28% of hospitalized patients requiring mechanical ventilators to help them breathe (for more than 48 hours) will develop ventilator-associated pneumonia. Current therapy involves intravenous antibiotics, but new antibiotics that can be inhaled (and more directly treat the infection) are being developed.

For a complete list of videos, visit our video library