Question

The nurse is entering a patient's data in the electronic health record. What action should the nurse take to minimize ambiguity and confusion?

1) Use consistent, codified terminology.
2) Record the data in the patient's presence.
3) Enter the data in the patient's native language.
4) Upload scanned copies of the patient's records.

Answer 1

To minimize ambiguity and confusion when entering a patient's data in the electronic health record, the nurse should use consistent, codified terminology, record the data in the patient's presence, and avoid entering the data in the patient's native language.

Step-by-step explanation:

In order to minimize ambiguity and confusion when entering a patient's data in the electronic health record, the nurse should take the following actions:

1. Use consistent, codified terminology: By using standardized terms and codes, the nurse ensures that the data is clear and can be easily interpreted by other healthcare professionals.
2. Record the data in the patient's presence: This helps to ensure accuracy and allows the patient to verify the information being entered.
3. Avoid entering the data in the patient's native language: While language preferences should be considered, maintaining data integrity and consistency is more important. Using a standardized language helps ensure that the information can be understood by all healthcare providers.