Author Question: The nurse avoids errors in documentation by following accepted guidelines when documenting in a ... (Read 111 times)

schs14

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The nurse avoids errors in documentation by following accepted guidelines when documenting in a client record, which include: Standard Text: Select all that apply.
 
  1. Describe what you think
  2. Quote client directly
  3. Describe observed behavior
  4. Leave spaces between entries per agency policy
  5. Write error through a mistaken entry

Question 2

The nursing student observes several admissions during the course of the clinical rotation. Which of the following would the student want to include during the admission of his first client? Standard Text: Select all that apply.
 
  1. Complete documentation fully
  2. Respect client's dress and dietary customs
  3. Leave the physical exam for the next shift
  4. Allow time for the client to rest after the process
  5. Complete the process as quickly as possible



dyrone

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Answer to Question 1

2,3
Rationale: An accurate entry records what the nurse sees and hears, not thoughts or opinions.

Answer to Question 2

1,2,4
Rationale: Complete admission documentation will ensure availability of the information to all caregivers.



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