A nurse is preparing to document a client's information in the electronic medical record.
Which of the following nursing statements identifies the purpose of documentation?
"Documentation enables providers to monitor the nurse.”.
"Documentation provides a communication tool for the health care team.”.
"Documentation provides information for a client audit.”.
"Documentation facilitates reimbursement from the local government.”.
The Correct Answer is B
Choice A rationale
While documentation can be reviewed by providers, its primary purpose is not to monitor nurses' performance. Monitoring occurs through various quality assurance processes, and documentation serves a broader range of functions beyond individual nurse oversight.
Choice B rationale
Documentation acts as a central communication hub for all members of the healthcare team, including physicians, nurses, therapists, and other specialists. It ensures continuity of care by providing a shared understanding of the client's condition, treatments, and responses, facilitating informed decision-making and collaboration.
Choice C rationale
Although documentation can be used for audits, such as financial or quality audits, this is not its primary purpose. The main goal of documentation is to provide a comprehensive record of patient care for effective communication and continuity.
Choice D rationale
While accurate documentation supports billing and reimbursement processes from various payers, including government entities, this is a secondary outcome. The primary aim of documentation is to ensure high-quality patient care through clear and comprehensive information sharing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The physician is responsible for medical diagnoses, which identify diseases or medical conditions based on the patient's signs, symptoms, and diagnostic test results. While nurses use medical diagnoses to inform their care, they do not analyze data to arrive at them.
Choice B rationale
The patient provides subjective data about their health status, which is crucial information for the nurse's assessment. However, the patient does not have the clinical knowledge and expertise to analyze and interpret this data in the context of other findings to formulate a nursing diagnosis.
Choice C rationale
The nurse is responsible for collecting, analyzing, and interpreting patient data (both subjective and objective) to identify patterns, draw conclusions about the patient's health status, and formulate nursing diagnoses. Nursing diagnoses describe the patient's responses to actual or potential health problems that nurses are qualified and licensed to treat.
Choice D rationale
Therapists, such as physical therapists, occupational therapists, or respiratory therapists, focus on specific aspects of the patient's rehabilitation and treatment based on their area of expertise. While they contribute valuable data to the patient's overall care, they are not primarily responsible for formulating nursing diagnoses.
Correct Answer is A
Explanation
Choice A rationale
This statement provides objective and descriptive information about the patient's condition following the venipuncture. It accurately describes the physical findings (painful, raised hematoma) and the location (outer left arm) and clearly links it to the medical procedure (after venipuncture) without making assumptions or assigning blame.
Choice B rationale
This statement is inappropriate as it is judgmental and accusatory towards the laboratory technician. Medical documentation should be objective and focus on the patient's condition and care, not on personal opinions or unsubstantiated claims about the skills of healthcare professionals.
Choice C rationale
This statement is speculative and attempts to explain the cause of the hematoma without factual basis. While patient movement can contribute to bruising, stating it as a likely cause without evidence is not objective documentation and could be inaccurate.
Choice D rationale
While this statement is factual in that it describes the presence of a bruise, it lacks important details such as the size, characteristics (e.g., raised, painful), and its direct association with the venipuncture, which are relevant for a comprehensive patient record.
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