Purposes/Reasons for Client Records
Purposes/Reasons for Client Records ( 5 Questions)
A nurse is documenting the care provided to a client in the electronic health record (EHR).
Which of the following actions should the nurse take?
(Select all that apply.).
Standardized terminology and abbreviations can improve communication, consistency and data collection among health care providers.
The date and time of each entry can provide accurate and timely information about the patient’s condition and care.
Deleting any incorrect information with a single line is not appropriate for electronic health records. Instead, the nurse should use the correction function of the EHR system to make any changes.
Signing each entry with the nurse’s name and credentials can ensure accountability and responsibility for the documentation.
Sharing the password with other authorized staff can facilitate access to the patient’s information when needed. However, the nurse should also protect the password and security of the EHR system by closing it when not in use and not disclosing it to unauthorized persons.
A. Use standardized terminology and abbreviations. This is correct because standardized terminology and abbreviations can improve communication, consistency and data collection among health care providers.
B. Include the date and time of each entry. This is correct because the date and time of each entry can provide accurate and timely information about the patient’s condition and care.
C. Delete any incorrect information with a single line.
This is wrong because deleting any incorrect information with a single line is not appropriate for electronic health records. Instead, the nurse should use the correction function of the EHR system to make any changes.
D. Sign each entry with the nurse’s name and credentials. This is correct because signing each entry with the nurse’s name and credentials can ensure accountability and responsibility for the documentation.
E. Share the password with other authorized staff.
This is correct because sharing the password with other authorized staff can facilitate access to the patient’s information when needed. However, the nurse should also protect the password and security of the EHR system by closing it when not in use and not disclosing it to unauthorized persons.
Normal ranges for date and time are based on the institution’s policy and standards.
Normal ranges for standardized terminology and abbreviations are based on the accepted sources such as NANDA, NIC, NOC, etc.