Question

20.) The nurse is orienting a new graduate nurse and reviewing documentation. Which documentation performance would include the best practice for charting? Select all that apply.

a. use long narratives to be sure that the documentation is understood.

b.) always use complete sentences

c.) always use the patients name in each entry

d.) use partial sentences/and or brief phrases

e.) only use approve abbreviations

Answer 1

b )always use complete sentences

(Reason--using a complete sentence for charting help easy to read and understand. The documentation must clearly indicate that individualized ,goal directed nursing care was provided to a patient based on the nursing assessment.)

e ) Only use approve abbreviations

(Reasons-The use of approved abbrevations help to save time and space and also it is necessary to avoid medication error.)

c)always use the patient name in each entry

(Reason-To keep the records accurate ,the patient name should be written on each page, and also include date and time.)