Asked by Katende Ludovic on Sep 27, 2024
A nurse is auditing and monitoring patients' health records. Which action is the nurse taking?
A) Determining the degree to which standards of care are met by reviewing patients' health records
B) Realizing that care not documented in patients' health records still qualifies as care provided
C) Basing reimbursement upon the diagnosis-related groups documented in patients' records
D) Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment
Auditing
The systematic examination and evaluation of records or financial accounts to ensure accuracy and compliance with established standards or regulations.
Diagnosis-Related Groups
A system of classification for hospital cases intended to standardize hospital billing.
Health Records
Documents containing the medical history, treatments received, diagnostic findings, and care outcomes of a patient.
- Absorb the essentials of documentation procedures, paying special attention to accurate charting and legal matters.
- Appreciate the role of nursing documentation in patient safety, care quality, and compliance with healthcare policies.
Learning Objectives
- Absorb the essentials of documentation procedures, paying special attention to accurate charting and legal matters.
- Appreciate the role of nursing documentation in patient safety, care quality, and compliance with healthcare policies.