The same nursing documentation record is used in every unit of a hospital. Why does a hospital use a standardized form for nursing documentation? (Choose all that apply.)

Question

a. Helps to provide continuity of care
b. Standardizes patient care parameters
c. Assists in maintaining confidentiality
d. Reduces the number of medication errors
e. Provides the foundation for staffing levels
f. Allows for quality evaluations between units

Answer 1

A, B, E, F

a. Correct. An institution uses the same nursing documentation record because it helps to provide continuity of care across various settings by providing organized, pertinent, and thorough health care data on a specific individual. Other units in the hospital and other health care settings have an easier time locating relevant data.
b. Correct. Specific health care data is found in one location on a standardized nursing do-cumentation record throughout an institution and provides the basis for standardized pa-tient evaluation across settings.
c. Incorrect. Nurses must restrict access to a standardized documentation record or any other type of patient record such as laboratory reports, narrative or progress notes, and other documents.
d. Incorrect. A standardized nursing documentation record can reduce a specific type of do-cumentation error but is unlikely to affect the rate of medication errors.
e. Correct. Standardized documents help to describe patient acuity levels and thus provide a justification for staffing.
f. Correct. Because the same parameters are, or should be, recorded across all units, the standardized documentation record allows for hospital-wide quality evaluations.