Author Question: The quality of the nurse's documentation says much about the kind of care that is given by the ... (Read 29 times)

itsmyluck · **on:** Jul 17, 2018

The quality of the nurse's documentation says much about the kind of care that is given by the nurse. Accurate and complete documentation is important for effective communication and accountability.

What are key guidelines that are generally accepted for documentation?
1 . Document what you hear.
2 . Be specific.
3 . Use direct quotes.
4 . Be prompt.
A) 1, 2, 3
B) 1, 2, 4
C) 1, 3, 4
D) 2, 3, 4

Question 2

A nurse is caring for a client with a pulmonary disorder and has to document the client's treatment and responses. For this, the nurse will have to use progress notes.

What information will be included on the client's treatment and responses on the MAR? A) Lists all the medications that the primary care provider has ordered for the client with spaces for the caregiver to mark when medications are given.
B) Documents large amount of information collected at intervals over a specified period of time in brief, concise entries.
C) At regular intervals, a summary of the client's condition or response to treatment is made.
D) Summarizes an account of a client's relationship with a healthcare facility.

jointhecircus · **Reply #1 on:** Jul 17, 2018

Answer to Question 1

D
Feedback:
Key guidelines that are generally accepted for documentation include document what you see, be specific, use direct quotes, and be prompt.

Answer to Question 2

A
Feedback:
Medication administration record lists all the medication that the primary care provider has ordered for the client. Flow sheet documents large amount of information collected at intervals over a specified period of time in brief, concise entries. Progress notes at regular intervals summarize the client's condition or response to treatment.
Health record is an account of a client's relationship with a healthcare facility.