Exam 10: Healthcare Team Communication: Documenting and Reporting

A concise document that provides most of the client's nursing and medical information is a(n):

Besides being an instrument of continuous client care, the client's medical record also serves as a(an):

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic client chart is:

A client's record can be more accurate if the nurse:

When a nurse recognizes having documented one client's assessment data on the wrong client's medical record, the nurse should:

Which principle should guide the nurse's documentation of entries on the client's medical record?

The client states, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today." The client's arms are folded across the chest. The brow is furrowed and the client refuses to allow morning vital sign measurements. Which entry should be included in the nurse's charting? Select all that apply.