a. Accurate documentation is needed for proper reimbursement.

d. High-quality nursing documentation reflects the nursing process.

d. It can be used as a tool for biomedical research and provide education.

a. Paper is fragile and susceptible to damage.

d. Use black ink unless the facility allows a different color.

c. Electronic health record (EHR)

a. They improve patient health status.

c. The nurse should never share any password with anyone.

a. Document facts and subjective data from the patient.

a. The nursing process

b. They are examples of problem-oriented charting.

d. Charting by exception

c. MAR

a. Admission summary

d. The medical record, in any format, is the most reliable source of information in a legal action.

b. Log-on access to the electronic record identifies the person charting.

c. Draw a single line through the error and write “error” above or after the entry, along with the nurse’s initials.

b. The order must be repeated verbatim to confirm accuracy.

c. Hand-off can lead to patient death if done incorrectly.