Accurate documentation by the nurse is necessary since proper ...

[jjjetplane]

Accurate documentation by the nurse is necessary since proper documentation:
 
  a. is needed for proper reimbursement.
  b. must be electronically generated.
  c. does not involve e-mails or faxes.
  d. is only legal if written by hand.

Question 2

The final phase of the nursing process is evaluation, which focuses on:
 
  a. recording the care that was implemented.
  b. medical and nursing goals for the welfare of the patient.
  c. long-term goals only.
  d. the patient responses to interventions and outcomes.

[mohan]

Answer to Question 1

ANS: A
Accurate documentation is necessary for hospitals to be reimbursed according to diagnostic-related groups (DRGs). DRGs are a system used to classify hospital admissions. Health care documentation is any written or electronically generated information about a patient that describes the patient, the patient's health, and the care and services provided, including the dates of care. These records may be paper or electronic documents, such as electronic medical records, faxes, e-mails, audiotapes, videotapes, and images.

Answer to Question 2

ANS: D
Evaluation is the final step in the nursing process. Evaluation focuses on the patient and the patient's response to nursing interventions and outcome attainment. Evaluation is not a record of care that was implemented. Patient outcomes serve as the criteria against which the success of a nursing intervention is judged. During the evaluation phase, nurses use critical thinking to determine whether a patient's short- and long-term goals were met and whether desired outcomes were achieved. Monitoring whether the patient's goals were attained is collaborative, involving the patient in the decision-making process.

[jjjetplane]

Excellent

[ghepp]

TYSM