Question

The nursing preceptor is preparing to speak with the new licensed practical/vocational nurse (LPN/LVN) regarding documentation. Which statement by the preceptor is correct?

a. "It is important to use only approved medical terms and abbreviations when
documenting in the electronic health record (EHR)."
b. "Our facility discourages nurses from using complete words when documenting because it takes up too much space in the chart."
c. "To prevent errors, our facility does not allow the use of abbreviations for documentation."
d. "The physician uses more abbreviations when writing orders than the nurse uses when documenting."

Answer 1

The correct statement is option a: "It is important to use only approved medical terms and abbreviations when documenting in the electronic health record (EHR)."

Step-by-step explanation:

The correct statement by the nursing preceptor is option a: "It is important to use only approved medical terms and abbreviations when documenting in the electronic health record (EHR)."

Using approved medical terms and abbreviations in EHR documentation is crucial for accurate and efficient communication among healthcare professionals. This helps to prevent misunderstandings and errors in patient care. It also ensures consistency and standardization in medical documentation.

While abbreviations can be used in EHR documentation, it should be done in accordance with facility policies and guidelines. It is important to avoid using unapproved abbreviations that may lead to confusion or misinterpretation.