Author Question: Review the charting sample and determine which documentation error occurred. 1000: Hygienic care ... (Read 46 times)

colton

  • Hero Member
  • *****
  • Posts: 627
Review the charting sample and determine which documentation error occurred.
 
  1000: Hygienic care given
  1100: Complaint of leg pain
  1300: Appetite good, resting comfortably
 
  a. Recording on the wrong chart
  b. Failure to document an intervention
  c. Failure to document a discontinued medication
  d. Failure to record outcome of an intervention

Question 2

A client is 3 days postoperative from gallbladder surgery secondary to gallstones. Domain: Physiological. Class: Fluid and electrolyte balance. Activity:
 
  Check intravenous fluid rate intake every hour. Which of the following nursing coding systems is represented in this situation?
 
  a. North American Nursing Diagnosis (NANDA)
  b. Nursing intervention classification
  c. Nursing outcome classification
  d. Omaha system of client problems



SamMuagrove

  • Sr. Member
  • ****
  • Posts: 312
Answer to Question 1

ANS: B
The nurse failed to document an intervention for the client's complaint of leg pain. The interventions are actions that nurses perform in settings relevant to illness prevention, illness treatment, and health promotion. There is no evidence the nurse has recorded on the wrong chart. There is no evidence the nurse has failed to document a discontinued medication. The nurse has recorded the outcome of an intervention by stating the client has a good appetite and is resting comfortably.

Answer to Question 2

ANS: B
The nursing intervention classification identifies nursing interventions that are classified under domains and classes. NANDA is a classification of nursing diagnoses. Nursing outcome classification identifies and classifies nursing-sensitive outcomes of client care. The Omaha system classifies problems under four levels: (1) major domains, (2) specific problems, (3) modifiers, and (4) signs and symptoms.



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question


 

Did you know?

Pope Sylvester II tried to introduce Arabic numbers into Europe between the years 999 and 1003, but their use did not catch on for a few more centuries, and Roman numerals continued to be the primary number system.

Did you know?

Ether was used widely for surgeries but became less popular because of its flammability and its tendency to cause vomiting. In England, it was quickly replaced by chloroform, but this agent caused many deaths and lost popularity.

Did you know?

Stroke kills people from all ethnic backgrounds, but the people at highest risk for fatal strokes are: black men, black women, Asian men, white men, and white women.

Did you know?

The longest a person has survived after a heart transplant is 24 years.

Did you know?

Studies show that systolic blood pressure can be significantly lowered by taking statins. In fact, the higher the patient's baseline blood pressure, the greater the effect of statins on his or her blood pressure.

For a complete list of videos, visit our video library