A nurse is discussing a client's needs at an interdisciplinary team conference.
The client had a stroke and requires inpatient rehabilitation incorporated into their plan of care.
Which of the nursing competencies is the nurse demonstrating?

Choice A rationale:

Charting by exception (CBE) is a documentation method in which the nurse documents only unexpected findings or significant deviations from the client's normal condition. It is based on the assumption that the client's baseline status remains within the expected range, and deviations from this norm are documented. CBE is efficient and allows nurses to focus on relevant and critical information, reducing unnecessary documentation. It is particularly useful in clinical settings where frequent assessments are needed.

Choice B rationale:

Focus charting (DAR) is another method of documenting client care that emphasizes a structured approach to documentation, with a focus on data, action, and response (DAR). While it provides a systematic way to document care, it does not necessarily limit documentation to only unexpected findings. Focus charting encourages documentation of care in a problem-oriented manner, which may include expected or routine assessments.

Choice C rationale:

Problem-oriented medical record (POMR) is a documentation system that focuses on organizing client information around specific healthcare problems or diagnoses. It encourages a problem-solving approach to care and promotes the inclusion of a comprehensive client history and care plan. POMR documentation may involve both expected and unexpected findings, so it does not limit documentation to only unexpected findings.

Choice D rationale:

SOAP documentation stands for Subjective, Objective, Assessment, and Plan. It is a structured method of documenting healthcare encounters. SOAP notes include a wide range of information, including both subjective (patient's description of symptoms) and objective (clinician's observations) data. While SOAP notes are organized, they do not specifically limit documentation to only unexpected findings.

The correct answer is Choice D: Obtaining a blood pressure for a client who is to be discharged later in the day.

Choice A rationale:

Providing tracheostomy care requires specialized training and assessment skills, which are beyond the scope of practice for assistive personnel (AP).

Choice B rationale:

Assessing a client who just returned from surgery involves clinical judgment and decision-making, which are responsibilities of a licensed nurse, not assistive personnel.

Choice C rationale:

Teaching a client how to use an incentive spirometer requires patient education skills and the ability to assess the client's understanding, which are tasks for a licensed nurse.

Choice D rationale:

Obtaining a blood pressure is a routine task that can be delegated to assistive personnel, as it does not require advanced clinical judgment or specialized training.