Exam 3: Documentation

A new patient is being admitted to a long-term care facility. Who has primary responsibility for each patient's initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified?

What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply.)

Twenty-four-hour charting is designed to establish __________ levels to help determine staffing needs.

What regulates standards for long-term care documentation?

What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record?

Who is the legal owner of the patient's medical record?

What are some problems associated with electronic (or computerized) charting? (Select all that apply.)

The best defense against malpractice claims associated with nursing care is accurate _____________.

When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?

What does documentation of type of care, time of care, and signature of the person prove?