Author Question: Documentation is a vital nursing role since the patient's health record: a. should be completed ... (Read 71 times)

SGallaher96 · **on:** Jul 23, 2018

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.

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

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.