Answer to Question 1
ANS: A
Record all entries legibly. Do not write personal opinions (belligerent). Enter only objective and factual observations of patient's behavior; quote all patient comments. Do not erase, apply correction fluid, or scratch out errors made while recording. Chart only for yourself.
Answer to Question 2
ANS: A
The auditing and monitoring of patients' health records involve nurses periodically auditing records to determine the degree to which standards of care are met and identifying areas needing improvement and staff development. The mistakes in documentation that commonly result in malpractice include failing to record nursing actions; this is the aspect of legal documentation. The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patient's recorded findings to determine whether the new method was more effective than the standard protocol. Data analysis contributes to evidence-based nursing practice and quality health care.
Schematic of an automated external defibrillator (AED) attached to a patient.
Localization of neurotransmitter action
Treating the pregnant patient
All messages must be documented and placed in the patient's chart.
Oral pseudo membraneous candidiasis in a patient with AIDS.
The phases of the action potential