Documentation Self-Assessment

n which of the following cases should a progress note be written?

- When admitting a patient - When receiving a patient postoperatively - When a procedure is performed

Which of the following data entries follows the recommended guidelines for documenting data?

Following oxygen administration, vital signs returned to baseline."

A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out?

Maintain it according to agency policy.

What is the primary purpose of an incident report?

Means of identifying risks

A nurse organizes patient data using the SOAP format. Which of the following would be recorded under "S" of this acronym?

Patient complaints of pain

What is the primary purpose of the patient record?

communication

A nurse administers a medication for pain but forgets to document it in the patient's medical record. Legally, what does this mean?

in the eyes of the law, if it is not documented, it was not done.

what is evaluated when conducting a nursing audit?

patient records