A nurse is educating a student nurse about the purpose of written documentation. The nurse recognizes that additional teaching is warranted when the student nurse states:
1. The purpose of written documentation is to communicate pertinent data to the health-care team.
2. The purpose of written documentation is to serve as a record of accountability for accreditation.
3. The purpose of written documentation is to serve as a legal record for the health-care provider only.
4. The purpose of written documentation is to serve as a record of accountability for quality assurance.
Question 2
While documenting in a patient's chart, a nurse recognizes that
1. Documentation serves as a temporary part of the medical record.
2. Documentation is one of the least important tasks performed in nursing.
3. Documentation is the act of charting only abnormal information related to a patient.
4. Documentation is evidence of what transpired during an event requiring medical care.
The nurse assesses the patient's ability to use the walker correctly
Example of variance documentation
Handwritten documentation.
Special Purpose Checks
Nurse administering enteral nutrition through a feeding tube.
The nurse begins the general survey