health assessment pt. 2.1 (documentation guidelines)

Question 1

• Use only commonly accepted
abbreviations, symbols and terms. Refer
to approved list given by the institution.

Answer 1

accepted terminology

Question 2

• Incorrect spelling gives a negative
impression to the reader and decreases
the credibility of the nurse

Answer 2

correct spelling

Question 3

Includes name and title of the nurse
• For electronic records each nurse has his
or her own code

Answer 3

signature

Question 4

• Client’s name and identifying information should be stamped or written on each page of the
clinical record. Do not identify charts by room number. Special care is needed when caring for
clients with the same last name.

Answer 4

accuracy

Question 5

Document events in the order in which they occur.

Answer 5

sequence

Question 6

Record only information that pertains to client’s health problems and care.
Recording irrelevant information may be considered invasion of client’s
privacy and/or libelous.

Answer 6

appropriateness

Question 7

Not all data that a nurse obtains about a client can be recorded. However,
the information that is recorded needs to be complete and helpful to the
client and the health care team.

Answer 7

completeness

Question 8

Recordings need to be brief as well as complete.
• Client’s name and the word “client” are omitted.
• End each thought with a period.

Answer 8

conciseness

Question 9

Accurate and complete documentation should give legal
protection to the nurse, the health care team and the
institution.
• Admissible in court as a legal document, the clinical
record provides proof of the quality of care given to the
client.

Answer 9

legal prudence