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

Author Question: Documentation is a vital nursing role since the patient's health record: a. should be completed ... (Read 70 times)

SGallaher96

  • Hero Member
  • *****
  • Posts: 509
Documentation is a vital nursing role since the patient's health record:
 
  a. should be completed accurately and in a timely manner.
  b. should not be computerized (EHR) because of disclosure risks.
  c. is not a legal document although they can be helpful in lawsuits.
  d. cannot be used in determining billing and reimbursement issues.

Question 2

The patient has an order for morphine sulfate 2 mg intravenously prn (as needed) every 2 hours. When the nurse administers this medication, she is providing:
 
  a. an independent nursing intervention.
  b. a dependent nursing intervention.
  c. a referral
  d. an indirect care procedure.



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question
Marked as best answer by a Subject Expert

leannegxo

  • Sr. Member
  • ****
  • Posts: 374
Answer to Question 1

ANS: A
All documentation entries should be completed in a timely, accurate, and professional manner. Documentation most often is charted in the patient's EHR and standardized flow sheets according to agency policy. Patient health records are legal documents. Within the Health Insurance Portability and Accountability Act (HIPAA) guidelines, patient documentation is provided to insurance companies and others for billing and reimbursement.

Answer to Question 2

ANS: B
Dependent nursing interventions are tasks that require an order from a physician or primary care provider (PCP). Independent nursing interventions are tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order. Referrals in health care involve sending a patient to another member of the interdisciplinary health care team for a consultation or other services. Indirect care includes nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients.




SGallaher96

  • Member
  • Posts: 509
Reply 2 on: Jul 23, 2018
Thanks for the timely response, appreciate it


rachel

  • Member
  • Posts: 323
Reply 3 on: Yesterday
Gracias!

 

Did you know?

The top five reasons that children stay home from school are as follows: colds, stomach flu (gastroenteritis), ear infection (otitis media), pink eye (conjunctivitis), and sore throat.

Did you know?

When blood is exposed to air, it clots. Heparin allows the blood to come in direct contact with air without clotting.

Did you know?

Sildenafil (Viagra®) has two actions that may be of consequence in patients with heart disease. It can lower the blood pressure, and it can interact with nitrates. It should never be used in patients who are taking nitrates.

Did you know?

Nitroglycerin is used to alleviate various heart-related conditions, and it is also the chief component of dynamite (but mixed in a solid clay base to stabilize it).

Did you know?

The U.S. Preventive Services Task Force recommends that all women age 65 years of age or older should be screened with bone densitometry.

For a complete list of videos, visit our video library