Author Question: Review the charting sample and determine which documentation error occurred. 1000: Hygienic care ... (Read 57 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?

The shortest mature adult human of whom there is independent evidence was Gul Mohammed in India. In 1990, he was measured in New Delhi and stood 22.5 inches tall.

Did you know?

Fungal nail infections account for up to 30% of all skin infections. They affect 5% of the general population—mostly people over the age of 70.

Did you know?

It is believed that humans initially contracted crabs from gorillas about 3 million years ago from either sleeping in gorilla nests or eating the apes.

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?

Signs and symptoms of a drug overdose include losing consciousness, fever or sweating, breathing problems, abnormal pulse, and changes in skin color.

For a complete list of videos, visit our video library