BN 3 Inpatient/Outpatient Documentation

Question 1

what type of information should be documented in Nursing notes?

Answer 1

mental status assessments, physical assessment, all nursing care, treatments, procedures, and patient education performed. Should include pertinent information about the patients condition, progress and response to treatment

Question 2

What are some examples of treatments and procedures that should be documented on the nursing note?

Answer 2

Wound care and dressing changes, any discontinuation or additional equipment, specimen collection, suture, staple or clip removal, respiratory treatments, IV site care, Iv tubing changes, IV solution changes, Insertion or removal of Foley catheter, Any type of isolation precautions and how the patient is psychologically responding.

Question 3

In regards to patient education, what should documentation on the nursing note include?

Answer 3

Patients level of comprehension, ability to repeat the skill or ability to demonstrate how to do a task

Question 4

What should be documented on the nursing not for a patient that has an adverse reaction to medication?

Answer 4

Type or signs and sxs, who was notified and what was done for the patient

Question 5

How do you correct a mistake made on a nursing note?

Answer 5

Draw a single line through, write “error” and your initials above, continue with correct info, do not erase or scribble through words

Question 6

How do you make a late entry into a nursing note?

Answer 6

Write late entry in the am/pm hour column followed by current time and date. Identify the actual time of occurrence within the note