POST TEST ND

What is the number to call if emergency situation happen in Malaysia?

• 66

• 999

• 911

• 994

What is documentation in nursing?

• Written client data

• Electronic client data

• Written and electronic client data

• Written and electronic client data, nursing clinical decisions and interventions and the client's responses in health record.

Purpose of documentation are below EXCEPT...

• As evidence in a court of law.

• For teaching new nurses and students in clinical area.

• For family members to keep at home after discharge.

• For communication among healthcare workers and other departments.

Which statement explain about Legible.

• Can use blue pen for documentation.

• Rub it by pen corrector or liquid paper.

• Draw a line to an error documentation through it and write above original entry.

• Errors occur while recording can be correct by draw a line through it and write above or next to original entry with your initial or name.

Which abbreviation use approved by RSH.

• TN

• TTH

• INS

• TCA

A good documentation must have this criteria.

• Advise to record in advance in case you forgot to write it when you busy.

• Nurse can share patient information on client's treatment when request by family members and friends.

• Date and time, sign name after each entry, chronological order and chart medication serve immediately.

• Entries in all spaces on all relevant assessment form are compulsory. Put (-) for items that do apply to your patient rather than leave it blank.

To keep client record in confidentiality manner

• Put client's folder at client's unit example on cardiac table while waiting for doctor.

• Can give information to legal advisor if they need client particular and health progress when request.

• Arrange client's folder at nurses station so that it easy to take when doctors come for morning round.

• Put the client's folder in the bag when transferring to other unit for any procedure or to other ward.

Which activities should enter timely.

• Changes in client status and who notified.

• Admission, transfer, discharge or death of the client.

• Vital signs, pain score assessment and administering medication.

• All the above

Organization, factual and current are part of the core principles of effective of documentation.

• True

• False

The importance of documentation for nurses are serve the guide of diagnosis and treatment.

• True

• False