Author Question: The nurse is charting in the paper medical record. She should: a. print his/her name since ... (Read 79 times)

kodithompson · **on:** Jul 23, 2018

The nurse is charting in the paper medical record. She should:

a. print his/her name since signatures are often not readable.
b. not document her credentials since everyone knows that she is a nurse.
c. skip a line, leaving a blank space, between entries so that it looks neater.
d. use black ink unless the facility allows a different color.

Question 2

Paper records are being replaced by other forms of record keeping because:

a. paper is fragile and susceptible to damage.
b. paper records are always available to multiple people at a time.
c. paper records can be stored without difficulty and are easily retrievable.
d. paper records are permanent and last indefinitely.

efwsefaw · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: D
Entries into paper medical records are traditionally made with black ink to enable copying or scanning, unless a facility requires or allows a different color. The date, time, and signature, with credentials of the person writing the entry, are included in the entry. No blank spaces are left between entries because they could allow someone to add a note out of sequence.

Answer to Question 2

ANS: A
Paper records have several potential problems. Paper is fragile, susceptible to damage, and can degrade over time. It may be difficult to locate a particular chart because it is being used by someone else, it is in a different department, or it is misfiled. Storage and control of paper records can be a major problem.