Author Question: A nurse is charting on a patient's record. Which action will the nurse take that is accurate ... (Read 58 times)

haleyc112

  • Hero Member
  • *****
  • Posts: 600
A nurse is charting on a patient's record. Which action will the nurse take that is accurate legally?
 
  a. Charts legibly
  b. States the patient is belligerent
  c. Writes entry for another nurse
  d. Uses correction fluid to correct error

Question 2

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking?
 
  a. Determining the degree to which standards of care are met by reviewing patients' health records
  b. Realizing that care not documented in patients' health records still qualifies as care provided
  c. Basing reimbursement upon the diagnosis-related groups documented in patients' records
  d. Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment



mk6555

  • Sr. Member
  • ****
  • Posts: 310
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.



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question

haleyc112

  • Hero Member
  • *****
  • Posts: 600
Both answers were spot on, thank you once again



mk6555

  • Sr. Member
  • ****
  • Posts: 310

 

Did you know?

According to the FDA, adverse drug events harmed or killed approximately 1,200,000 people in the United States in the year 2015.

Did you know?

Congestive heart failure is a serious disorder that carries a reduced life expectancy. Heart failure is usually a chronic illness, and it may worsen with infection or other physical stressors.

Did you know?

Not getting enough sleep can greatly weaken the immune system. Lack of sleep makes you more likely to catch a cold, or more difficult to fight off an infection.

Did you know?

Asthma occurs in one in 11 children and in one in 12 adults. African Americans and Latinos have a higher risk for developing asthma than other groups.

Did you know?

There are actually 60 minerals, 16 vitamins, 12 essential amino acids, and three essential fatty acids that your body needs every day.

For a complete list of videos, visit our video library