This topic contains a solution. Click here to go to the answer

Author Question: How should the nurse correct an error in charting? a. remove the sheet with the error and replace ... (Read 39 times)

kshipps

  • Hero Member
  • *****
  • Posts: 571
How should the nurse correct an error in charting?
 
  a. remove the sheet with the error and replace it with a new sheet with the correct entry.
  b. scribble out the error and rewrite the entry correctly.
  c. draw a single line through the error, and then write error above or after the entry
  d. leave the entry as is and tell the charge nurse.

Question 2

The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. The best central location to obtain this information is the:
 
  a. admission summary.
  b. discharge summary.
  c. flow sheet.
  d. Kardex.



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question
Marked as best answer by a Subject Expert

frejo

  • Sr. Member
  • ****
  • Posts: 349
Answer to Question 1

ANS: C
Documentation mistakes must be acknowledged. If an error is made in paper documentation, a line is drawn through the error and the word error is placed above or after the entry, along with the nurse's initials and followed by the correct entry. Notes should never be altered or obliterated. Documentation mistakes must be acknowledged.

Answer to Question 2

ANS: A
An admission summary includes the patient's history, a medication reconciliation, and an initial assessment that addresses the patient's problems, including identification of needs pertinent to discharge planning and formulation of a plan of care based on those needs. The discharge summary addresses the patient's hospital course and plans for follow-up, and it documents the patient's status at discharge. It includes information on medication and treatment, discharge placement, patient education, follow-up appointments, and referrals. Flow sheets and checklists may be used to document routine care and observations that are recorded on a regular basis, such as vital signs, medications, and intake and output measurements. Although computerization of records may mean that the Kardex system is no longer active, the term kardex continues to be used generically for certain patient information held at the nurses' station.



kshipps

  • Hero Member
  • *****
  • Posts: 571
Both answers were spot on, thank you once again



frejo

  • Sr. Member
  • ****
  • Posts: 349

 

Did you know?

All adverse reactions are commonly charted in red ink in the patient's record and usually are noted on the front of the chart. Failure to follow correct documentation procedures may result in malpractice lawsuits.

Did you know?

Critical care patients are twice as likely to receive the wrong medication. Of these errors, 20% are life-threatening, and 42% require additional life-sustaining treatments.

Did you know?

The effects of organophosphate poisoning are referred to by using the abbreviations “SLUD” or “SLUDGE,” It stands for: salivation, lacrimation, urination, defecation, GI upset, and emesis.

Did you know?

Immunoglobulin injections may give short-term protection against, or reduce severity of certain diseases. They help people who have an inherited problem making their own antibodies, or those who are having certain types of cancer treatments.

Did you know?

Barbituric acid, the base material of barbiturates, was first synthesized in 1863 by Adolph von Bayer. His company later went on to synthesize aspirin for the first time, and Bayer aspirin is still a popular brand today.

For a complete list of videos, visit our video library