.png){kind=logo}
1. Patient Record:
Answer
• Compilation of patient's health information
• Only permanent legal document that details nurse's interactionsw/Pt
2. Why do we Keep Official PT Records?:
Answer
• COMMUNICATION BETWEEN DIS-CIPLINES
• Legal documentation
• Financial
• Education
• Research
• Auditing/monitoring
3. Never Document:
Answer -An intervention prior to performing it
4. EHR (electronic health record):
Answer
•Benefits
-Physicians, nurses, other healthcare workers have immediateaccess (no searching for the
patient record)
-No lost records
5. EHR Consists of:
Answer
• Admission
• Orders
• Progress notes
• Nurse's admission assessment
NSG 321 Test 2 Documentation Complete And Study material 8pages LEARNEXAMS
What's included in this material?
-
Up-to-date Content: This is the latest version of the study guides, questions, and answers.
-
Instant Access: Immediately available for download right after your purchase.
-
Multi-Device: High-quality PDF format, easily readable on your phone, tablet, or PC.
-
Verified Quality: Carefully curated content designed to help you prepare effectively.
Sample Content from this Document
UNLOCK ACCESS
$35.00
.png)