A nurse is teaching a newly hired nurse about the legal aspects of documentation.
Which of the following statements by the newly hired nurse indicates an understanding of the teaching?
“I should document only normal findings to avoid alarming the client.”.
“I should document any incident that occurs during my shift and notify the provider.”.
“I should document in advance to save time and ensure accuracy.”.
“I should document my personal opinions about the client’s condition and care.”.
The Correct Answer is B
“I should document any incident that occurs during my shift and notify the provider.” This statement indicates an understanding of the legal aspects of documentation, which include:.
• Documenting accurately, objectively, and completely to provide evidence of care delivery and support the nurse’s moral and legal responsibilities.
• Documenting any change in the patient’s condition, treatments, medications, interventions, client responses, and complaints.
• Documenting any incident that occurs during the shift and notifying the provider to ensure appropriate follow-up and prevent further harm.
• Documenting in a timely manner to minimize errors and omissions.
The other choices are wrong because:.
• Choice A is wrong because documenting only normal findings can mislead the client and other health professionals about the actual status of the client. It can also impede patient care and hinder the nurse’s legal defense in the event of a malpractice lawsuit.
• Choice C is wrong because documenting in advance can compromise the accuracy and integrity of the documentation. It can also lead to legal action if the documented events do not match the actual events.
• Choice D is wrong because documenting personal opinions about the client’s condition and care can be considered unprofessional, biased, and disrespectful. It can also damage the nurse-client relationship and expose the nurse to legal liability.
Normal ranges for documentation depend on the type of information being documented, such as vital signs, laboratory values, assessment findings, etc.
They may vary according to different sources and standards.
Nurses should follow the policies and procedures of their institution and use their clinical judgment when documenting abnormal findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Home health certification and plan of treatment.This is the record that the nurse uses to certify that the client meets Medicare eligibility criteria and to outline the services to be provided.A home health certification and plan of treatment is a document that contains the physician’s or allowed practitioner’s orders for home health services, the patient’s diagnosis, the patient’s functional limitations, the type and amount of services needed, and the expected duration of care.
Choice B is wrong becauseOutcome and Assessment Information Set (OASIS)is a standardized assessment tool that HHAs use to collect data on adult patients receiving skilled services.
OASIS is not used to certify eligibility or plan treatment.
Choice C is wrong becauseHome care flow sheetis a form that HHAs use to document the daily care provided by nurses and home health aides.
A home care flow sheet does not certify eligibility or plan treatment.
Choice D is wrong becauseHome care progress noteis a form that HHAs use to document the patient’s progress toward the goals of care, any changes in the plan of care, and any communication with other health care providers.
A home care progress note does not certify eligibility or plan treatment.
Correct Answer is ["A","B"]
Explanation
These are the only options that describe thesubjectiveandobjectivedata of the patient, which are part of theSOAPdocumentation method.SOAP stands forSubjective, Objective, Assessment, and Plan, and it is a way of recording patient data in a clear and consistent manner.
ChoiceCis wrong because wound culture results are not part of the assessment entry in SOAP documentation.They are part of the investigation results, which are usually documented in the objective section.
ChoiceDis wrong because risk for infection related to impaired skin integrity is a nursing diagnosis, not an assessment.Nursing diagnoses are usually documented in the plan section of SOAP documentation.
ChoiceEis wrong because applied moist heat compresses to the wound site is an intervention, not an assessment.Interventions are also documented in the plan section of SOAP documentation.
Normal ranges for vital signs are as follows:.
• Blood pressure: 90/60 mmHg to 120/80 mmHg.
• Pulse rate: 60 to 100 beats per minute.
• Respiratory rate: 12 to 20 breaths per minute.
• SpO2: 95% to 100%.
• Temperature: 36.5°C to 37.5°C.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.