Question
To ensure accurate charting, which actions should the nurse perform? Select all that apply.
Includes interpretations of client behavior Charts that the client is ingesting sufficient quantity of food and fluids Checks to make sure that the nurse has the correct chart prior to making an entry Documents interventions as close as possible to the time of execution Places a label with the client's name and identification number on each page of the client's chart
Includes interpretations of client behavior Charts that the client is ingesting sufficient quantity of food and fluids Checks to make sure that the nurse has the correct chart prior to making an entry Documents interventions as close as possible to the time of execution Places a label with the client's name and identification number on each page of the client's chart
Answers
Answered by
GPT-4o mini
When ensuring accurate charting, the nurse should perform the following actions:
1. **Checks to make sure that the nurse has the correct chart prior to making an entry:** This is essential to avoid errors and ensure that the documentation is accurate and pertains to the correct patient.
2. **Documents interventions as close as possible to the time of execution:** Timely documentation is crucial for maintaining accurate and reliable patient records. It ensures that the information is fresh and reflects the true state of patient care.
3. **Places a label with the client's name and identification number on each page of the client's chart:** This helps to prevent any mix-ups and ensures proper identification of the patient throughout the documentation process.
The other options are not appropriate practices:
- **Includes interpretations of client behavior**: Charting should be objective and factual, and it is not appropriate to include personal interpretations or subjective opinions unless clearly stated as such in a manner that supports the observations.
- **Charts that the client is ingesting sufficient quantity of food and fluids**: It's critical to document actual intake rather than just stating assumptions about adequacy. This should be based on direct observations and data.
So, the correct actions to take for accurate charting are the first, second, and third options.
1. **Checks to make sure that the nurse has the correct chart prior to making an entry:** This is essential to avoid errors and ensure that the documentation is accurate and pertains to the correct patient.
2. **Documents interventions as close as possible to the time of execution:** Timely documentation is crucial for maintaining accurate and reliable patient records. It ensures that the information is fresh and reflects the true state of patient care.
3. **Places a label with the client's name and identification number on each page of the client's chart:** This helps to prevent any mix-ups and ensures proper identification of the patient throughout the documentation process.
The other options are not appropriate practices:
- **Includes interpretations of client behavior**: Charting should be objective and factual, and it is not appropriate to include personal interpretations or subjective opinions unless clearly stated as such in a manner that supports the observations.
- **Charts that the client is ingesting sufficient quantity of food and fluids**: It's critical to document actual intake rather than just stating assumptions about adequacy. This should be based on direct observations and data.
So, the correct actions to take for accurate charting are the first, second, and third options.
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