A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)
Wait until the end of the shift to document
Cover errors with correction fluid, and write in the correct information
Use as many abbreviations as possible to save space
Document objective data, leaving out opinions
The date and time should be included with each entry
Correct Answer : D,E
A. Wait until the end of the shift to document: Documentation should be done promptly after care is provided to ensure accuracy and completeness. Delaying documentation increases the risk of errors or omissions.
B. Cover errors with correction fluid, and write in the correct information: Errors should never be covered with correction fluid. Instead, a single line should be drawn through the mistake, followed by the correction and the nurse’s initials.
C. Use as many abbreviations as possible to save space: Only approved abbreviations should be used to avoid misinterpretation and increase clarity. Overuse of abbreviations can lead to confusion.
D. Document objective data, leaving out opinions: Documentation should be factual and objective (e.g., "Patient grimaced when moving" instead of "Patient appears to be in pain"). Subjective or opinion-based language should be avoided.
E. The date and time should be included with each entry: Every entry must have a date and time to provide an accurate timeline of care, ensuring legal protection and continuity of care.
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Correct Answer is C
Explanation
A. It increases cost.: While initial implementation is costly, computerized charting ultimately reduces costs by improving efficiency and reducing errors.
B. It promotes individualization of the medical record.: Computerized systems standardize documentation rather than individualizing it. However, personalization can be added through specific notes.
C. It improves legibility.: Handwritten notes can be illegible, leading to errors. Computerized charting eliminates handwriting issues and ensures clarity.
D. It minimizes the number of forms to be completed.: While it may reduce paperwork, it does not necessarily minimize documentation, as structured data entry is still required.
Correct Answer is C
Explanation
A. Signs: Signs are objective findings (e.g., fever, rash), observed by the nurse.
B. Objective cues: Objective cues are measurable and observable, whereas subjective data is based on the patient’s self-report.
C. Symptoms: Symptoms (e.g., pain, nausea, dizziness) are subjective because they cannot be measured directly and are reported by the patient.
D. Observable data: Observable data includes measurable signs, making it objective, not subjective.
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