Nurs1000 – Documentation Exam Questions With 100% Verified Answers
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Course
Nurs1000
Institution
Nurs1000
Nurs1000 – Documentation Exam Questions
With 100% Verified Answers
Standards of practice for nursing documentation - answermust be accurate, comprehensive, and
flexible enough for members of the health care team to retrieve critical data, maintain continuity
of care and track patient outcomes...
Nurs1000 – Documentation Exam Questions
With 100% Verified Answers
Standards of practice for nursing documentation - answer✔must be accurate, comprehensive, and
flexible enough for members of the health care team to retrieve critical data, maintain continuity
of care and track patient outcomes, and it must reflect current standards of nursing practice.
confidentiality of nursing documentation - answer✔a nurse is legally and ethically obligated to
keep information about patients confidential
PIPEDA - answer✔Personal Information Protection and Electronic Documents Act
A federal legislation protecting personal information, including health information.
Professional misconduct - answer✔failing to keep records as required
falsifying a record
signing or issuing a document that the member knows includes a false statement
giving information about a client without consent
Charting by exception - answer✔charting deviations from established norms or abnormal
findings
case management plan - answer✔incorporates a multidisciplinary approach to documenting
patient care
critical pathways or care maps - answer✔multidisciplinary care plans that include patient health
concerns, key interventions, and expected outcomes within an established time frame
source records - answer✔the patients chart is organized so that each discipline has a separate
section in which to record data
narrative documentation - answer✔the use of story-like format to document information specific
to patient conditions and nursing care
problem orientated medical records - answer✔a method of documentation that emphasizes the
patients problems
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