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

the specific time of all sudden changes in the patient's condition

the period the shift covers

every 2 hours

every hour on the hour

Answer and Explanation

The Correct Answer is A

A. The specific time of all sudden changes in the patient's condition: Timely documentation of sudden changes ensures accuracy in patient records and supports clinical decision-making.

B. The period the shift covers: While shift documentation is important, it does not replace event-specific charting.

C. Every 2 hours: Documentation frequency depends on patient status; critical changes require immediate recording, not just every 2 hours.

D. Every hour on the hour: Routine hourly documentation is unnecessary unless required by patient condition (e.g., ICU monitoring).

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Correct Answer is A

Explanation

A. Confidentiality: The biggest concern is maintaining patient confidentiality due to risks of unauthorized access, hacking, and breaches of protected health information (PHI).

B. Adequate forms for documentation: Computerized charting typically has structured templates, ensuring that all necessary fields are included.

C. Incorrect information: While errors can occur, computerized charting often includes safeguards like drop-down menus, alerts, and validation checks to reduce mistakes.

D. None of the answers are correct: Confidentiality is a significant concern, making option A the best answer.

A. omission exists B. failure exists C. variance exists D. error exists

Correct Answer is C

Explanation

A. Omission exists: An omission means something was left out, but that does not fully explain why the projected outcome was not met.

B. Failure exists: The term failure is not a standard term in critical pathways. The situation could be due to various factors beyond "failure."

C. Variance exists: A variance occurs when the patient’s progress deviates from the expected outcome within a critical pathway. This can be positive (faster recovery) or negative (delay in progress).

D. Error exists: A variance is not necessarily an error, as some patients may require longer recovery times due to medical conditions.

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

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Naxlex Comprehensive Predictor Exams

What is the major concern when using a computer for documentation?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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