Review the charting sample and determine which documentation ...

[colton]

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]

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.

[colton]

Correct answers!

[SamMuagrove]

Great! Please up vote