When Documenting Patient Care, the Nurse Recognizes That Which of the Following

question 10

Multiple Choice

When documenting patient care, the nurse recognizes that which of the following is true about documentation of care?

• A) Every nurse should anticipate having patients' records subpoenaed at some time during his or her nursing career.
• B) There is a need for quicker documentation that does not reflect the nursing process.
• C) The legal assumption is that care was given even if it is not documented.
• D) Any method of documentation that provides comprehensive, factual information is legally unacceptable.

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Definitions:

Handwriting Recognition

The ability of a computer to interpret and convert human handwriting into text or commands.

Document Management

Refers to the processes and practices used for managing, storing, and tracking documents within an organization.

Medicare CCI

Stands for Correct Coding Initiative under Medicare, which is designed to prevent improper payments where incorrect code combinations are billed.

Encoder Software

Computer software used to convert data into a particular format, often used for compressing video or audio data.