Which of the following is an example of good charting?
"No complaints of pain or discomfort."
The patient states, "It feels like a knife stabbing me."
"Lump diminished."
"Patient's condition much better today than yesterday."
The Correct Answer is B
thoroughly. The patient may not have verbalized pain but could still be experiencing it.
B. The patient states, "It feels like a knife stabbing me.": This documents subjective data verbatim using the patient’s exact words, which is best practice for accuracy and clarity.
C. "Lump diminished.": This lacks specificity—the exact size, texture, or other changes should be documented using precise measurements (e.g., “Lump decreased from 3 cm to 2 cm”).
D. "Patient's condition much better today than yesterday.": This is too vague and lacks measurable indicators of improvement (e.g., vital signs, pain level, mobility).
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Related Questions
Correct Answer is D
Explanation
A. The insulin was administered per the nurse's testimony: In legal cases, verbal testimony alone is not sufficient without documentation.
B. None of the answers are correct: One of the answers is correct based on legal documentation principles.
C. The insulin was administered based on the witness testimony: Even though there were witnesses, medication administration must be documented for legal and clinical accountability.
D. The insulin was not administered because it was not charted: "If it wasn't documented, it wasn't done." In legal and medical practice, lack of documentation means the action cannot be verified as completed.
Correct Answer is ["A","B"]
Explanation
A. Repeat the details of the prescription back to the provider: Verbal/telephone orders must be read back to ensure accuracy (known as read-back verification).
B. Record the reason for the call made to the provider and the results of the call in the Nurse’s Notes: Documentation should include:
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Why the call was made
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Provider’s response and order
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Patient’s condition before and after intervention
C. Tell the charge nurse that the provider has prescribed morphine by telephone: While communication with the charge nurse is good practice, it does not replace proper documentation and verification.
D. Refuse to accept the verbal prescription because this is not an emergency: While verbal orders should be limited to emergencies, they can be accepted in certain non-emergency cases, provided read-back verification and documentation are done.
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