Exam 7: Documentation of Nursing Care

A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to have the medical record to take, because it is her personal property. An appropriate response would be:

The Quality and Safety Education for Nurses (QSEN) project has identified the most important pre-licensing skills for nurses as:

A nurse enters a notation in a patient's medical record but then discovers that the notation was made in the wrong chart. The nurse correctly:

The nurse is with a patient who 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 primary care provider requesting that the primary care provider examines the patient for unexpected complications. This documentation by the nurse is likely to:

When using a case management system of charting a __________, an unexpected event in the patient's condition is documented on the back of the pathway sheets.

Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?

Health care professionals assigned to a patient require access to the medical record to review information and to document care given. All contents of the medical record must be kept ___________. The contents of the medical record should not be discussed with persons who are not involved in the care of the patient.

The nurse understands that a face sheet contains information pertaining to: