Accurate documentation by the nurse is necessary since proper documentation:
a. is needed for proper reimbursement.
b. must be electronically generated.
c. does not involve e-mails or faxes.
d. is only legal if written by hand.
ANS: A
Accurate documentation is necessary for hospitals to be reimbursed according to diagnostic-related groups (DRGs). DRGs are a system used to classify hospital admissions. Health care documentation is any written or electronically generated information about a patient that describes the patient, the patient's health, and the care and services provided, including the dates of care. These records may be paper or electronic documents, such as electronic medical records, faxes, e-mails, audiotapes, videotapes, and images.
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