Documentation

Question 1

The Use and disclosure of information should be _________.

Answer 1

limited

Question 2

Client’s chart should be appropriately ___________.

Answer 2

safeguarded

Meaning, it should only be on the nurse’s station

Question 3

Disclosure of information must be with client’s _________.

Answer 3

consent

That doesn’t mean that patients have an access on their chart

Question 4

Clients have the right to _____________.

Answer 4

information

Question 5

The patient can’t access their charts but can see their _______________.

Answer 5

Medical record with proper procedure

They need to request it first.

Question 6

Client’s have the right to __________ information.

Answer 6

supplement

These are extra information. If they have a surgery tomorrow and they dont know what to do. It is their right to be guided and informed about what may happen.

Question 7

What are the 3 Elements of Documentation?

Answer 7

1. • Concise
   • Complete
   • Confidential
   • Accurate
2. • Appropriate
   • Legible
3. • Legal Prudence
   • Timely

Question 8

Can patients see their charts?

Answer 8

No

Question 9

Other nurses not assigned are _________ to access the chart.

Answer 9

not allowed

Question 10

All of the information of the patient should to others.

A. not be shared
B. be shared

Answer 10

A. not be shared

Question 11

Everything on the chart should be _.

A. incorrect
B. correct

Answer 11

B. correct

Obvious ba?

Tama dapat as everything on the chaart, nurses are liable.

Question 12

When you want to erase something on the chart, draw a (a)_______________ and write (b)______ on the side and (c)________.

Answer 12

a. horizontal line

b. error

c. sign

Question 13

If you will do a process or make the patient take medication but they refuse, that should be ____________.

Answer 13

recorded

May waiver form ka na ibibigay na kailangan nilang i-accomplish.

Question 14

If…

• The client wants to see his chart.
• The client wants to photocopy his chart

What will you do?

Answer 14

Use the hospital’s protocol.

The institution is the rightful owner of the chart!

Say to the patient that they can’t see their chart and tell them to request it to medical records.

Question 15

If the patient requests to see his/her medical record, use your facilities form or have the patient draft a _______ to see his/her medical record.

Answer 15

written request

Question 16

COMPUTER RECORDS

Personal ___________ is required.

Answer 16

password

Your password is your property.

Question 17

COMPUTER RECORDS

Never leave the terminal ______________.

Answer 17

unnattended

Question 18

COMPUTER RECORDS

Do not leave the client information ____________ on the monitor.

Answer 18

displayed

Lock your computer. If anything happens like leaking of information. It will be your responsibility.

Question 19

COMPUTER RECORDS

_______ all unneeded computer generated worksheets.

Answer 19

Shred

If information is printed. Shred it after.

Question 20

COMPUTER RECORDS

Know the facility’s __________________.

Answer 20

policy and procedure

Question 21

COMPUTER RECORDS

IT must install a ___________ to protect server from unauthorized access.

Answer 21

firewall

Question 22

Documenting should be done ______ after an assessment or an intervention.

Answer 22

ASAP

Question 23

Documentation should _______________ before providing nursing care.

Answer 23

not be done

DO NOT WRITE ANYTHING AHEAD OF TIME!

Document the date and time of each recording.

Question 24

Record time according to the ________ (military time).

Answer 24

24-hour clock

Pero pwede din yung 12-hour clock

Question 25

Documentation should be entered in a ______________.

Answer 25

**chronological manner**

Question 26

Recording should give a lot of information **clearly but in a few words.** A. Legible B. Concise C. Legal Prudence

Answer 26

**B. Concise**

Question 27

Records should be **readable**. A. Legible B. Concise C. Legal Prudence

Answer 27

A. Legible

Question 28

**Informed consent** (Verbal and written). A. Legible B. Concise C. Legal Prudence

Answer 28

C. Legal Prudence ## Footnote **Written consent is best consent** because verbal can be forgotten and changed.

Question 29

In ____________ CONSENT, the doctor will explain the benefits and risks.

Answer 29

**INFORMED**

Question 30

The consent should be signed by the patient and doctor who will ______________ .

Answer 30

**do the procedure** ## Footnote *The one who will get the consent and sign the form is the one who will do the procedure.* **(But it is not the case in the Philippines)**

Question 31

Give **4** Nurse's Notes

Answer 31

* Medication sheet * Vital signs sheet * Intake and Output Monitoring Sheet * Discharge note

Question 32

On the nurse's notes, _______ other empty spaces.

Answer 32

**cross out** ## Footnote *Baka may mag sign pang iba.*

Question 33

If a student nurse sign the medication, it will not be valid. It should be ___________ by the Clinical Instructor.

Answer 33

**countersigned**

Question 34

This is used **for endorsements**. **Medical-Patient Information System** which uses forms pre-printed on durable card stock.

Answer 34

**Kardex**

Question 35

What should you use on the **Kardex**?

Answer 35

Always use **PENCIL**.

Question 36

**Demographics** on the Kardex should be written using ______.

Answer 36

**PEN**

Question 37

Can we use **telephone order**?

Answer 37

**YES** | During EMERGENCY ONLY!

Question 38

When the physician order something through telephone order, ________ order to the physician.

Answer 38

**repeat**

Question 39

Write details in Physician Order Sheet and get a _____________.

Answer 39

**witness** | TWO NURSES must verify order for safety!

Question 40

Require MD to co-sign the telephone order in the Physician Order sheet within ____________.

Answer 40

**24 hours** ## Footnote *Report if not signed!*