Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

Incident reports must be recorded in the nurse's notes

Institutions are only reimbursed for patient care that is documented

Document only when not successful

The patient record is a complete picture of individualized problems, treatments and responses to treatments

Answer and Explanation

Correct Answer : B,D

A. Incident reports must be recorded in the nurse's notes: Incident reports should not be recorded in the patient’s chart. They are used internally to improve patient safety and should be kept separate from the medical record.

B. Institutions are only reimbursed for patient care that is documented: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as documentation serves as proof that care was provided.

C. Document only when not successful: Documentation should be comprehensive, including both successful and unsuccessful interventions, to provide a full picture of patient care.

D. The patient record is a complete picture of individualized problems, treatments, and responses to treatments: A patient's medical record includes their health status, nursing interventions, and responses, making it a complete reference for continuity of care.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

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.

A. Physician's Order Sheet B. Narcotic Administration Sheet C. Care Plan D. MAR and Narcotic Administration Sheet

Correct Answer is D

Explanation

A. Physician's Order Sheet: While the physician orders narcotics, administration is not documented here.

B. Narcotic Administration Sheet: The Narcotic Administration Sheet is specifically for controlled substances, ensuring proper tracking and preventing misuse.

C. Care Plan: The care plan outlines patient goals and interventions, not medication administration.

D. MAR (Medication Administration Record) and Narcotic Administration Sheet: The MAR (Medication Administration Record) documents all medications given to the patient. The Narcotic Administration Sheet is required for controlled substances to comply with regulations.

View Question and Answer

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

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

Correct Answer is B

Explanation

On what form/forms should the nurse chart when administering a narcotic?

Correct Answer is D

Explanation

When documenting events in a patient's chart, the nurse should chart:

Which part of the medical record can be used as evidence in court?

Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

In which step of the nursing process do nurses look at outcomes?

The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

Who should document care in the patient record?

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)