Nursing documentation is an important part of effective ...

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Nursing documentation is an important part of effective communication among nurses and with other health care providers. As such, the nurse:
 
  a. documents facts.
  b. documents how he/she feels about the care being provided.
  c. documents in a block fashion once per shift.
  d. double documents as often as possible in order to not miss anything.

Question 2

The nurse is caring for patients on unit that uses electronic health records (EHRs). In order to protect personal health information, the nurse should:
 
  a. allow only nurses that she knows and trusts to use her verification code.
  b. not worry about mistakes since the information cannot be tracked.
  c. never share her password with anyone.
  d. be aware that the EHR is sophisticated and immune to failure.

[mrphibs]

Answer to Question 1

ANS: A
Nursing documentation is an important part of effective communication among nurses and with other health care providers. Documentation should be factual and nonjudgmental, with proper spelling and grammar. Events should be reported in the order they happened, and documentation should occur as soon as possible after assessment, interventions, condition changes, or evaluation. Each entry includes the date, time, and signature with credentials of the person documenting. Double documentation of data should be avoided because legal issues can arise as a result of conflicting data.

Answer to Question 2

ANS: C
Access to an EHR is controlled through assignment of individual passwords and verification codes that identify people who have the right to enter the record. Passwords and verification codes should never be shared with anyone. Health care information systems have the ability to track who uses the system and which records are accessed. These organizational tools contribute to the protection of personal health information. Disadvantages of use of computers for documentation include computer and software failure and problems if there is a power outage.

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Gracias!

[Joy Chen]

TYSM