Chapter 7: Documentation of Nursing Care – Flashcards

The nurse with a patient complains of severe pain documents every 15 minutes about the steps taken to try to relieve the pain (without success). The nurse also documents the time and content of two calls made to the patient's physician requesting that the position examine the patient for unexpected complications. This documentation by the nurse is likely to do: A. Cause the physcian to come to the attention of the hospital administration B.be questioned by the nurse's supervisor for time inefficiency C. Be used against the nurse if a lawsuit results, because it proves the nurse was not able to relieve the pain. D. Justify insurance reimbursement for an extended duration of hospitalization for the patient

A patient who is very angry and is leaving the hospital against medical advice(AMA) demands to have the medical chart because it is her personal property. An appropriate response would be: A. "Certainly. This hospital doesn't need to keep it if you are leaving and will not be returning here" B. "You are entitled to the information in your chart, but the chart is the property of the hospital. I will see about having a copy made for you" C. "The information in your chart is confidential, and you cannot leave this facility with it" D. "because you are leaving against medical advice of your physician, you may not have the chart"

A student nurse is assigned to a clinical unit on which one of the patients is a nationally known celebrity. The student reads the chart to find out why the celebrity is being treated. The student who is not the assigned caregiver is: a. motivated to learn about the health problem of this patient and is appropriately seeking knowledge during his clinical experience. b. doing appropriate research about nursing care as long as information is not divulged. c. violating the confidentiality of the patient's record. d. neglecting the assigned patient load and should read the unassigned patient's chart only after his assigned work is completed

A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced by disruption of skin surface has the following nursing documentation: "Incision clean, dry, intact. No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from clothing. Verbalizes understanding of wound care and ability to manage at home. Wound healing without complication." This documentation is: a. an example of charting by exception. b. evidence of the use of the nursing process. c. using the problem-oriented medical record (POMR) format. d. usually entered on a flow sheet for treatments and vital signs.