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Documentation Questions and Answers (Q&A)

John Smith
Answered: Jul 11, 2020
Sometimes used by government agencies to evaluate patient care
It is a permanent record for accountability
It is a legal record of care
Can be used for research, teaching and data...Read More

1 Answer

237 views
John Smith
Answered: Jul 11, 2020
Charting interventions in advance to save time
Documenting incorrect data
Not charting the correct time when events took place
Not recording verbal orders or not having them signed....Read More

1 Answer

236 views
John Smith
Answered: Jul 11, 2020
Admission sheet and physician s orders
2. Progress notes and nurse s admission information
3. History and Physical Examination Data
4. Care plan and nurse s notes

P. 142

1 Answer

233 views
John Smith
Answered: Jul 11, 2020
Be certain that entry is factual even when opinions are used

P. 141, Table 7.2

1 Answer

233 views
Wyatt Williams
Answered: Jul 11, 2020
I am required to give you a request form so that I can prove you wanted your records and not just anyone else.

P. 152

1 Answer

230 views
John Smith
Answered: Jul 11, 2020
Patient states "sharp, shooting pain. Patient guards abdomen and refuses lunch tray
Related to unknown cause
Demerol 100 mg given IM
States the "pain is gone"

P. 145, figure...Read More

1 Answer

216 views
John Smith
Answered: Jul 11, 2020
Documentation only in hand written format even when EMR is mandated

P. 141

1 Answer

213 views
Wyatt Williams
Answered: Jul 11, 2020
PIE is from a nursing process. SOAPE is from a medical model

P. 145

1 Answer

212 views
John Smith
Answered: Jul 11, 2020
Data, action, response and evaluation, education and patient teaching
2. Data is both subjective and objective
3. Action combines planning and implementation
4. Response is the same as...Read More

1 Answer

212 views
John Smith
Answered: Jul 11, 2020
Helps eliminate unnecessary record keeping forms
Enhances efficiency because flow sheets and checklists are often used.
Accommodates a 24-hour period

P. 149

1 Answer

212 views
John Smith
Answered: Jul 11, 2020
REVISIONS are noted in the EVALUATION section

P. 144

1 Answer

212 views
John Smith
Answered: Jul 11, 2020
I am required to give you a request form so that I can prove you wanted your records and not just anyone else.

P. 152

1 Answer

211 views
John Smith
Answered: Jul 11, 2020
Both on the page entitled Works Cited and in alphabetical order by author

1 Answer

206 views
John Smith
Answered: Jul 11, 2020
Federal Health Care Agencies such as VA hospitals

P. 152

1 Answer

204 views
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