Preparation for the Nursing Laboratory

Question 1

What is integrated report writing?

Answer 1

A single patient record containing chronological entries made by all health care professionals involved in the person’s care

Question 2

Define date and time in terms of documenting

Answer 2

• Document data and time for legal reasons and for patient safety
• Record in 24 hour time or using AM and PM
• Double check electronic charts for a time stamp

Question 3

Define timing in terms of documenting

Answer 3

• Follow policy regarding frequency of documenting and increase if needed due to seriousness of condition
• No documenting should come before care but should be priority after assessment

Question 4

Define legibility in terms of documenting

Answer 4

• Must be legible to prevent misinterpretation

- Usually hand printing is recommended

Question 5

Define permanence in terms of documenting

Answer 5

• All entries must be made in black ink

Question 6

Define accepted terminology in terms of documenting

Answer 6

• Use only accepted abbreviations, symbols and terms

- Terminology may be generalised to the industry or specialised to the organisation

Question 7

Define correct spelling in terms of documenting

Answer 7

• Spelling is essential for accuracy in documentation

Question 8

Define signature in terms of documenting

Answer 8

• Each recording must be officially signed by a health practitioner

Question 9

Define accuracy in terms of documenting

Answer 9

• Person’s name and information should be attached and correct
• When a mistake is made, draw a singular line through the mistake

Question 10

Define sequence in terms of documenting

Answer 10

• Document in order of events occurring

Question 11

Define appropriateness in terms of documenting

Answer 11

• Record only information pertaining to the patient’s healthcare
• Appropriate language is required

Question 12

Define completeness in terms of documenting

Answer 12

• Information recorded must be completed and reflect the nursing process
• Recordings written in sentences

Question 13

Define conciseness in terms of documenting

Answer 13

• Recordings need to be brief and to the point

- The patient’s name and ‘patient’ is omitted

Question 14

Define legal prudence in terms of documenting

Answer 14

• Provides information about care delivered to a person that can act as legal document as evidence in court