If an agency is using computer-assisted charting, the nurse is responsible for:
Guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal.
Learning the passwords of the staff nurses and primary care providers so that they can communicate with one another.
Choosing whether he will use the computer to help in documentation or continue to use traditional paper documentation.
Patient education to input information about herself, such as intake and output or symptoms the patient may experience.
The Correct Answer is A
A. Guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal. Protecting patient confidentiality is essential in electronic charting to prevent unauthorized access.
B. Learning the passwords of the staff nurses and primary care providers so that they can communicate with one another. Sharing or learning others' passwords violates security protocols and confidentiality rules.
C. Choosing whether he will use the computer to help in documentation or continue to use traditional paper documentation. In facilities using electronic charting, all staff are typically required to use the system to maintain consistent, accessible records.
D. Patient education to input information about herself, such as intake and output or symptoms the patient may experience. Patients typically do not have access to chart directly into their medical records.
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Correct Answer is A
Explanation
A. Follows agency policy for correcting the error.
Following agency policy is the best approach, as it ensures compliance with legal and procedural standards for correcting documentation errors.
B. Whites out the wrong entry and writes the note in the chart of the correct patient. Whiting out errors is not permissible, as it can appear as an attempt to alter records and compromises the integrity of documentation.
C. Removes the page on which the error is located and documents the other correct notes. Removing pages from a medical record is improper and could be considered tampering with documentation.
D. Blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin "wrong patient," his signature, and the date and time.
Blacking out notes is not allowed, as it destroys information that should remain legible, even if it was written in error.
Correct Answer is C
Explanation
A. "Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch."
This documentation provides details but lacks specific information on the pain’s nature and duration.
B. "Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch."
This statement includes diet details but lacks a pain intensity rating and specific location.
C. "Periumbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids." This statement is the most thorough, including location, nature, intensity, duration, and lack of relief from interventions.
D. "Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse."
This is incomplete, as it lacks a specific location and description of the pain’s onset.