Chapter 26, Problem 8RQ

Summary Introduction

Introduction:

The documentation is one of the important practices in the nursing care plan as well as for hospital procedure for patient information that are legalized. The documentation by the nurse gives important information about the patient. The documentation will be in the form of medical records, nursing records, and handing-over documents. The medical record holds the information about the patient what type of disease the patient suffering. The nursing records contain the in-ward documents from the time the patient got admitted, records of the patient vitals, medicines are taken, and till the time of discharge. The informatics in nursing aids in the documentation, research, education, and administration.

Correct answer:

While working on a unit within a hospital, the nurse was able to access a patient’s medical record and review the education that other nurses provided during an initial hospitalization and three subsequent clinic visits that occurred in different provider’s office over the past 6 months. This type of feature is most common in an Electronic health record.