Nursing documentation should fulfill which of the following ...

[Mr3Hunna]

Nursing documentation should fulfill which of the following criteria? (Select all that apply.)
 
  1. Accurate
  2. Inclusive
  3. Well organized
  4. Show continuity of care
  5. Record nursing opinion
  5. Record nursing opinion
  6. Identify client outcomes

Question 2

Which of the following is an example of an intervention used in the Prob-lem-Intervention-Evaluation documentation method?
 
  1. Risk for injury related to falling due to dizziness
  2. Client fell while walking to bathroom unassisted
  3. Client continues to report periods of dizziness upon sitting up
  4. Educated to the purpose of dangling on the bedside before standing

[zacnyjessica]

Answer to Question 1

ANS: 1, 2, 3, 4, 6
Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. Nursing documentation should include nursing observations, not nursing opinions.

Answer to Question 2

ANS: 4
The problem is reflected by a nursing diagnosis while the interventions are related to nursing ac-tions directed toward minimizing or eliminating the problem. The evaluation is the client's objec-tive or subjective response to the nursing intervention.