The nurse works in a small hospital that uses narrative documentation rather than computer documentation. The nurse makes a practice of documenting care only at the end of the shift, just before giving shift report
Which aspect of documentation credibility does this most clearly violate?
1. It is contemporaneous.
2. It is accurate.
3. It is truthful.
4. It is appropriate.
Correct Answer: 1
Documentation should be contemporaneous (documented at the time it is provided), accurate, truthful, and appropriate. In this case, the most clearly violated aspect is that of being contemporaneous. Although documenting late may impact the accuracy and truthfulness of the notes, the nurse may be very accurate and very truthful, but just late in documenting. The documentation may be appropriate for the care provided even though it is late.
You might also like to view...
The nurse accepts a new job as a manager, spending much more time doing desk work instead of patient care
After a week in the new job, the nurse experiences pain in the right wrist and an ache around the shoulders and back. What is the most likely cause of these discomforts? 1. A stressful work environment 2. Lack of management skills 3. Poor body mechanics when using the computer 4. Lack of cooperation from staff
Health promotion differs from illness prevention in that health promotion
a. addresses identified health problems. b. occurs before the identification of disease risk factors. c. identifies and ameliorates a health problem. d. returns an individual to optimal functioning after an illness.
The nurse is writing a care plan for a patient with brain metastases. Following a thorough assessment, the nurse decides that an appropriate nursing diagnosis is "Anxiety related to lack of control over the health care needs and situation
" In establishing this plan of care for the patient, the nurse will identify what measure as appropriate for the care of this patient? A) The patient will receive antianxiety medications every 4 hours. B) The patient's family will be instructed on measures to implement when providing care for the patient. C) The patient will be encouraged to verbalize concerns related to the disease and its treatment. D) The patient will begin a busy schedule of therapy, so that he will forget about the anxiety.
The nurse is preparing to assess a toddler. To make the assessment go smoothly, before examining the child the nurse should first:
1) Talk to the mother before talking to the child. 2) Ask the child about his favorite toy. 3) Get the child's height and weight. 4) Ask the mother to undress the child.