HESI Medical-Surgical LPN/PN WITH ALL THE ANSWERS 2021

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The nurse is providing care for a patient who is unhappy with the health care provider’s care. The patient signs the Against Medical Advice (AMA) form and leaves the hospital against medical advic... e. What should the nurse include in the documentation of this event in the patient’s medical record or on the AMA form? 1. Documentation that the patient was informed that he or she cannot come back to the hospital 2. Documentation that the patient wasinformed that he orshe wasleaving against medical advice 3. Documentation that the risks of leaving against medical advice were explained to the patient 4. Documentation of any discharge instructions given to the patient 5. Documentation indicating an incident report has been completed Correct Answer: 2,3,4 Rationale 1: It should be clearly documented that the patient was advised and understands that he or she can come back. Rationale 2: It should be clearly documented in the patient’srecord and on the AMA form that the patient was advised that he or she was leaving against medical advice. Rationale 3: It should be clearly documented that the patient understandsthe risks of leaving against medical advice. Rationale 4: The AMA form includes the name of the person accompanying the patient and any discharge instructions given. Rationale 5: Facility policy may require that an incident report be completed, but it must not be referenced in the chart. The patient’srecord is a legal document, so the nurse should never document that he or she filed an incident report. Question 2 A nurse documents this statement in a patient’s medical record: “2/25/–, 2235. At 2015 patient awoke suddenly and complained ofshortness of air. Pulse oximetry reading was 82% on room air and audible wheezes could be heard.” This documentation meets which documentation guidelines [Show More]

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