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Documentation Questions and Answers (Q&A)

The correct answer to this question is C, Data entry. Adding information to a person's health care record is very important. It keeps every informed and up to date on what has been done, and it is for the patient's safety to ensure things like overdosage and incorrect diagnosis doesn't occur.

A nurse or doctor can use audio, or video record their interactions with a patient and then transcribe the recording to add it to their record. Charting has all of the patient's information, including their medications, progress, and plans for their treatment. The document includes both mapping and recording because these actions are forms of documenting all that has been done with the patient.

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The DARE format is known to be something that nurses refer to when they want to do proper documentation of effects regarding their patients. There are certain things that will be discussed such as the date and time when the patient was admitted or when an event has occurred. It will also discuss the patient’s vital signs and the pain status that the patient was feeling.

This is not a one-time thing. Nurses would need to constantly document to see if the condition of the patient is progressing or worsening. Take note that the information should be placed in a sequential manner to make things easier to assess and understand.

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The answer here for this question would be the first option and that is that the traditional way of medical record charting has an abbreviated story where the problem oriented version of charting shows everything done in an outline form. The traditional medical record charting would have a small summary of how an incident happened on up to what the patient was treated with and what doctors were used to treat the patient.

The problem oriented way of medical record charting is done in outline form and breaks everything down right to the smallest details. The traditional way was one that has been done for years and years and it really made it easier for the doctors to explain things especially to family members. The problem oriented medical record charting method breaks everything down in detail and it really helps cover the tracks of the attending physicians to make sure that the treatment protocol has been followed right down to the most exact of details.

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D. Focus can be a medical diagnosis Focus charting is used to describe a perspective of a patient. It is a method that health professionals used to organize the records of a patient’s health information. This type of charting can be described as a systematic approach to recording or documenting a patient’s health status and the required nursing action needed.

The aim of focus charting is to bring back the focal point of the nursing care to the patient and his or her worries, instead of focusing on a list of problems and medical diagnosis. This type of care incorporates various aspects of patient care processes.

1 Answer

All Agencies have their own policies for the documentation, thus different institoution can follow different approach to clinical pathway

1 Answer

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