Which of the following is a true statement about documentation? ...

[ss2343]

Which of the following is a true statement about documentation?
 
  a. Nurses should keep records of patients' wishes.
  b. Patients do not have access to their own medical records.
  c. The OASIS is a complete record of the health status of a patient.
  d. The nurse is responsible for completing all of the Minimum Data Set (MDS).

Question 2

Which of the following characteristics of RA are unlike those of OA?
 
  a. Myalgia and stiff-ness c. Crepitus and insta-bility
  b. Joint pain that is curable d. Systemic and symmetrical

[adammoses97]

Answer to Question 1

A

Feedback
A Correct. Entering patients' expressed wishes in the medical or clinical record helps ensure that the interdisciplinary team respects those wishes.
B Incorrect. According to regulations following HIPAA, the patient has access to his or her own medical records and may designate others to have access.
C Incorrect. The OASIS is used to measure outcomes for quality improvement purposes. It does not contain all necessary information for care, such as vital signs.
D Incorrect. The MDS should be completed jointly by all members of the interdis-ciplinary team.

Answer to Question 2

D
OA is not a systemic disease, nor does it affect joints symmetrically. Myalgia and stiffness are characteristics of PMR; however, myalgia is uncharacteristic of RA and OA. Joint pain is cha-racteristic of both RA and OA, but only OA is curable through joint replacement. RA is a sys-temic disease and affects joints symmetrically; therefore these are clinical indicators of OA, not RA.

[ss2343]

Excellent

[coreycathey]

TYSM