Which of the following is true regarding nursing documentation?
a. Standards for documentation are established by a national commission.
b. Medical records should be accessible to everyone.
c. Documentation should not include the patient's diagnosis.
d. High-quality nursing documentation reflects the nursing process.
ANS: D
The ANA's model for high-quality nursing documentation reflects the nursing process and includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and retrievability. Standards for documentation are established by each health care organization's policies and procedures. They should be in agreement with The Joint Commission's standards and elements of performance, including having a medical record for each patient that is accessed only by authorized personnel. General principles of medical record documentation from the Centers for Medicare and Medicaid Services (2010) include the need for completeness and legibility; the reasons for each patient encounter, including assessments and diagnosis; and the plan of care, the patient's progress, and any changes in diagnosis and treatment.
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