Answer to Question 1
ANS: A
Record all entries legibly. Do not write personal opinions (belligerent). Enter only objective and factual observations of patient's behavior; quote all patient comments. Do not erase, apply correction fluid, or scratch out errors made while recording. Chart only for yourself.
Answer to Question 2
ANS: A
The auditing and monitoring of patients' health records involve nurses periodically auditing records to determine the degree to which standards of care are met and identifying areas needing improvement and staff development. The mistakes in documentation that commonly result in malpractice include failing to record nursing actions; this is the aspect of legal documentation. The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patient's recorded findings to determine whether the new method was more effective than the standard protocol. Data analysis contributes to evidence-based nursing practice and quality health care.
Patient with exophthalmos.
Mechanisms of Action of Antiulcer Drugs
An example of an intake screen in an electronic health record.
Sites of Action of the Diuretics
The two mechanisms for terminating neurotransmitter action in the synapse: reuptake and enzymatic ...
Nurse measuring the recumbent height of a toddler