Expected nursing documentation includes: (Select all that apply.) ...

[abc]

Expected nursing documentation includes: (Select all that apply.)
 
  a. nursing assessment.
  b. the care plan.
  c. critique of the physician's care.
  d. interventions.
  e. patient responses to care.

Question 2

The nurse is charting using electronic documentation. With electronic documentation:
 
  a. errors can be corrected and totally removed from the record in the screen view.
  b. log-on access to the electronic record identifies the person charting.
  c. each entry requires the nurse to sign her/his name and credentials.
  d. documenting significant changes in the electronic record ends the nurse's responsibility.

[phuda]

Answer to Question 1

ANS: A, B, D, E
Expected nursing documentation includes a nursing assessment, the care plan, interventions, the patient's outcomes or response to care, and assessment of the patient's ability to manage after discharge. Documentation should be factual and nonjudgmental.

Answer to Question 2

ANS: B
Log-on access to the electronic record identifies the person charting or making a change. If an error is made in electronic documentation, it can be corrected on the screen view but the error and correction process remains in the permanent electronic record. Any correction in documentation that indicates a significant change in patient status should include notification of the primary care provider.

[abc]

TYSM

[LVPMS]

Excellent