Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:
patient's nursing problem
interventions carried out to meet the patient's needs
patient's medical problem
the patient's response to the intervention carried out
The Correct Answer is B
A. Patient's nursing problem: Nursing problems are identified in assessments, not the actual care documentation.
B. Interventions carried out to meet the patient’s needs: Documentation should include interventions, the time they were performed, and the caregiver’s signature for legal and professional accountability.
C. Patient’s medical problem: Medical problems are diagnosed by physicians, while nurses document care interventions related to nursing diagnoses.
D. The patient's response to the intervention carried out: While patient responses should be documented, this question focuses on recording interventions, not patient reactions.
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Correct Answer is B
Explanation
A. Validated data: While accurate data is crucial, validated data alone does not form a nursing diagnosis.
B. Data clustering: Data clustering involves grouping related signs, symptoms, and risk factors to determine patterns that lead to a nursing diagnosis.
C. Subjective data: Subjective data (e.g., pain, nausea) is part of assessment but must be combined with objective data to establish a diagnosis.
D. Objective data: Objective data (e.g., lab results, physical exam findings) is important, but a nursing diagnosis requires a comprehensive approach, including data clustering.
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.
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