A nurse is documenting a client’s admission assessment using a flow sheet.

Which of the following information should be included in a flow sheet?

(Select all that apply.).

Vital signs.

Allergies.

Medication administration.

Medical history.

Intake and output.

Answer and Explanation

Correct Answer : A,B,C,E

A flow sheet is a type of document that records routine and frequent data in a graphical or tabular form. It is used to monitor and evaluate the patient’s condition and response to treatment over time. A flow sheet should include information that is relevant, concise and easy to read.

• Choice A is correct because vital signs are one of the most common and important data that need to be recorded and monitored regularly for any patient.

• Choice B is correct because allergies are essential information that can affect the patient’s treatment plan and prevent adverse reactions.

• Choice C is correct because medication administration is another crucial data that shows what drugs, doses, routes and times the patient has received or will receive.

• Choice D is wrong because medical history is not a routine or frequent data that needs to be recorded in a flow sheet. Medical history is usually documented in a separate form that provides more details and background information about the patient’s past and present health conditions.

• Choice E is correct because intake and output are important data that indicate the patient’s fluid balance and renal function.

They need to be recorded and monitored regularly, especially for patients who have fluid restrictions.

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Correct Answer is ["A","B","D"]

Explanation

Choice A is correct because using standardized terminology and abbreviations can improve the clarity, accuracy, and consistency of the documentation in an EHR system.

• Choice B is correct because entering data as soon as possible after providing care can ensure the timeliness, completeness, and validity of the information in an EHR system.

• Choice C is wrong because sharing login information with other authorized users can compromise the security, privacy, and integrity of the EHR system.HIPAA guidelines require that each user has a unique identifier and password to access the EHR system.

• Choice D is correct because reviewing and verifying data before saving or submitting can prevent errors, omissions, and discrepancies in the EHR system.

• Choice E is wrong because correcting errors by drawing a single line through them is a method used for paper records, not electronic records.Electronic records should have a mechanism to track changes and corrections without altering the original data.

:HIPAA Guidelines for Electronic Medical Records:Electronic Health Records - Health IT Playbook.

A. Specifies the plan of care for clients with different diagnoses. B. Provides guidelines for managing clients with similar health problems. C. Describes the roles and responsibilities of each member of the health care team. D. Evaluates the quality and cost-effectiveness of care delivered to clients.

Correct Answer is B

Explanation

A critical pathway provides guidelines for managing clients with similar health problems.According to the definition from Wikipedia, a critical pathway is one of the main tools used to manage the quality in healthcare concerning the standardisation of care processes.It has been shown that their implementation reduces the variability in clinical practice and improves outcomes.

Choice A is wrong because a critical pathway does not specify the plan of care for clients with different diagnoses, but rather for a specific group of patients with a predictable clinical course.Choice C is wrong because a critical pathway does not describe the roles and responsibilities of each member of the health care team, but rather defines, optimizes and sequences the different tasks (interventions) by the professionals involved in the patient care.Choice D is wrong because a critical pathway does not evaluate the quality and cost-effectiveness of care delivered to clients, but rather aims to promote organised and efficient patient care based on evidence-based medicine.

Normal ranges for COPD are: FEV1/FVC ratio < 0.7; FEV1 < 80% predicted; FVC normal or reduced; TLC > 80% predicted; RV > 120% predicted; DLCO < 80% predicted.

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A nurse is documenting a client’s admission assessment using a flow sheet. Which of the following information should be included in a flow sheet? (Select all that apply.).

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A nurse is using an electronic health record (EHR) system to document the care provided to a client who has pneumonia. The nurse should follow which of the following guidelines when using an EHR system ? (Select all that apply.).

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is B

Explanation

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A nurse is documenting a client’s admission assessment using a flow sheet.

Which of the following information should be included in a flow sheet?

(Select all that apply.).