Exam 4: Documentation and Informatics

The nurse manager is attempting to determine the staffing needs of the unit.One tool that she may use to determine the level of care needed would be:

The patient was in bed with all side rails up.During the night,the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails.After meeting the patient's needs and assessing that the patient was not harmed,what step should the nurse take (if any)?

To limit liability,nursing documentation must clearly indicate that the nurse provided individualized,goal-directed nursing care to a patient based on the _____________________.

Which of the following is the best example of accurate documentation?

___________________ provide a format for documenting a patient's health status and progress.