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Author Question: A nurse is charting on a patient's record. Which action will the nurse take that is accurate ... (Read 50 times)

haleyc112

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on: Jul 22, 2018
A nurse is charting on a patient's record. Which action will the nurse take that is accurate legally?
 
  a. Charts legibly
  b. States the patient is belligerent
  c. Writes entry for another nurse
  d. Uses correction fluid to correct error

Question 2

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking?
 
  a. Determining the degree to which standards of care are met by reviewing patients' health records
  b. Realizing that care not documented in patients' health records still qualifies as care provided
  c. Basing reimbursement upon the diagnosis-related groups documented in patients' records
  d. Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment


mk6555

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Reply #1 on: Jul 22, 2018
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.


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haleyc112

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Reply #2 on: Jul 22, 2018
Both answers were spot on, thank you once again


mk6555

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Reply #3 on: Jul 22, 2018
Great! Please up vote :D


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