A nurse is providing teaching to a newly licensed nurse about the purpose of documentation in the client's health record.
Which of the following information should the nurse include?

Choice A rationale:

The statement "Identifies viruses across the world" is not an accurate description of the Healthy People 2030 framework. This framework focuses on health objectives and goals for Americans, not the identification of viruses. It is designed to improve the health and well-being of people in the United States, not to identify viruses globally.

Choice C rationale:

The statement "Utilizes health data from the past 20 years" is not a primary purpose of the Healthy People 2030 framework. While it may incorporate historical health data to inform its objectives, the framework's main goal is to set health objectives for the future, not exclusively based on past data. It aims to address current and future health needs and challenges.

Choice D rationale:

The statement "Monitors nonmodifiable risk factors" does not accurately describe the main focus of the Healthy People 2030 framework. While the framework may consider various health risk factors, it primarily concentrates on setting health objectives and goals to improve the health of Americans. The monitoring of nonmodifiable risk factors is not its central purpose.

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.