Ace the 2025 Arizona NCIA Exam – Lead with Confidence in Nursing Care!

Question: 1 / 520

What key information must an order include?

The name of the resident only

The specific illness the resident has

The date and time it is entered in the medical record

A key aspect of proper medical documentation is ensuring that orders are clear, precise, and include essential information. When an order is entered into a medical record, it is crucial to document the date and time the order is made. This information provides a timeline for the care provided, which is important for both continuity of care and legal purposes. Clinicians and staff need to understand when certain decisions were made to monitor the patient's condition and treatment effectively.

Having the date and time documented is particularly important for decision-making, as it allows healthcare professionals to track changes in a patient's health status and respond accordingly. For example, if a treatment needs to be adjusted or reviewed based on the patient's condition, knowing the timing of previous orders can inform best practices and help avoid potential medication errors.

The other options, while they contain relevant information in certain contexts, don’t encompass the criticality of the date and time entry in the medical record. The name of the resident, specific illnesses, and location of the care facility are all important but do not hold the same significance in defining the timing and sequence of care actions, which is central to managing patient care.

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The physical location of the care facility

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