Clinical Document Policy And Nursing Document Orientation

1. Documentation promotes continuity of care through intra/inter-professional communication, it demonstrates Tulip Health Care staff's commitment to providing safe, competent and ethical care.

True

False

Documentation promotes continuity of care by ensuring that important information about a patient's condition, treatment, and progress is recorded and easily accessible to all healthcare professionals involved in their care. This allows for effective communication and collaboration between different members of the healthcare team, both within and between professions. By documenting their actions and decisions, Tulip Health Care staff show their dedication to delivering safe, competent, and ethical care, as it provides a clear record of their accountability and adherence to professional standards. Therefore, the statement is true.

Explanation

Documentation promotes continuity of care by ensuring that important information about a patient's condition, treatment, and progress is recorded and easily accessible to all healthcare professionals involved in their care. This allows for effective communication and collaboration between different members of the healthcare team, both within and between professions. By documenting their actions and decisions, Tulip Health Care staff show their dedication to delivering safe, competent, and ethical care, as it provides a clear record of their accountability and adherence to professional standards. Therefore, the statement is true.

2. What is the best action when you made a mistake on patient progress note?

Use the eraser and write in the same space again.

Underline the sentence.

Underline the word/ words, write a word error above the word and write your initial.

When a mistake is made on a patient progress note, the best action is to underline the word/words that contain the error, write a word error above the word, and then write your initials. This ensures that the mistake is clearly identified and attributed to the correct person. Using an eraser and writing in the same space again may cause confusion and make it difficult to identify the correction. Underlining the sentence alone does not specify which word is incorrect, making it less effective in correcting the mistake.

Explanation

When a mistake is made on a patient progress note, the best action is to underline the word/words that contain the error, write a word error above the word, and then write your initials. This ensures that the mistake is clearly identified and attributed to the correct person. Using an eraser and writing in the same space again may cause confusion and make it difficult to identify the correction. Underlining the sentence alone does not specify which word is incorrect, making it less effective in correcting the mistake.

3. It is the responsibility of the THC staff to maintain their knowledge in documentation and management of health care records consistent with the requirements of this policy.

True

False

The statement is true because it states that it is the responsibility of the THC staff to maintain their knowledge in documentation and management of health care records. This means that the staff members are expected to stay up to date with the policies and requirements for handling health care records. By doing so, they can ensure that the records are managed properly and in accordance with the guidelines set forth in the policy.

Explanation

The statement is true because it states that it is the responsibility of the THC staff to maintain their knowledge in documentation and management of health care records. This means that the staff members are expected to stay up to date with the policies and requirements for handling health care records. By doing so, they can ensure that the records are managed properly and in accordance with the guidelines set forth in the policy.

4. Determine the admission date of the patient with MRN 2015-11-057.

November 2015

May 2015

May 2016

November 2016

The admission date of the patient with MRN 2015-11-057 is November 2015.

Explanation

The admission date of the patient with MRN 2015-11-057 is November 2015.

5. What are the important details need to write in Daman Attendance Sheet Sub-form A?

Name and Signature of the patient or Patient's relative

Name, Profession and the license number of the Staff Nurse

Patient's Name and Patient's Daman ID

Scoring Grid Score

The important details that need to be written in Daman Attendance Sheet Sub-form A include the name and signature of the patient or patient's relative, the name, profession, and license number of the staff nurse, and the patient's name and Daman ID. These details are necessary for accurate record-keeping and identification purposes.

Explanation

The important details that need to be written in Daman Attendance Sheet Sub-form A include the name and signature of the patient or patient's relative, the name, profession, and license number of the staff nurse, and the patient's name and Daman ID. These details are necessary for accurate record-keeping and identification purposes.

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