Sample interview questions: How do you ensure proper documentation and record-keeping in pediatric nursing?
Sample answer:
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Accurate and Timely Documentation:
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Record observations, assessments, interventions, and patient responses promptly and accurately.
- Ensure that all documentation is legible, complete, and signed with your name and credentials.
- Use standardized forms, protocols, and templates to facilitate uniformity and completeness of records.
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Document using electronic health records (EHR) or paper charts as per institutional policies.
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Patient Identification:
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Verify the patient’s identity using multiple identifiers such as name, date of birth, medical record number, and wristband.
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Ensure that all documentation, including progress notes, medication administration records, and laboratory results, is linked to the correct patient.
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Assessment and Evaluation:
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Conduct thorough and comprehensive assessments of the child’s physical, psychological, and social status.
- Document baseline data, including vital signs, growth parameters, nutritional status, developmental milestones, and family history.
- Monitor changes in the child’s condition and document any deviations from normal.
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Evaluate the effectiveness of nursing interventions based on the child’s response and adjust care accordingly.
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Medication Administration:
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Verify medication orders, including dosage, frequency, route, and timing, with the prescriber or author… Read full answer
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