NSG 321 Test 2 Documentation (Complete And Verified Study material) (8pages) LEARNEXAMS

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