Documentation should include:
1. objective and subjective data.
2. observations made by other nursing staff.
3. information that is accurate and complete.
4. incidence reports.
3
Documentation should be clear, concise, complete, and accurate.
You might also like to view...
An older woman tearfully tells a nurse, "I must buy my neighbor all of his groceries, or he will not drive me to the store or the doctor." This is an example of which type of elder mistreatment?
a. Financial exploitation b. Psychological abuse c. Caregiver neglect d. Abandonment
A client is very upset that he recently had a vasectomy but his wife got pregnant anyway. When taking a history on this client, which question should the nurse specifically ask?
a. "After the operation, did you use ice for more than 2 days?" b. "Did you return for a follow-up sperm count?" c. "Have you considered paternity testing?" d. "Were you told about the lifting restrictions?"
The majority of abdominal aortic aneurysms are due to
A. Trauma B. Infection C. Inflammation D. Atherosclerosis
Which nursing report recommended that nursing education move away from the system of apprenticeship that predominated at the time and move toward a planned program of education similar to that offered by other professions?
A) The Surgeon General's Consultant Group Report on Nursing B) The Brown Report C) The American Nurses Association Position Paper D) The Pew Health Profession Commission Study