A nurse is using the focus charting method to document care for a client who has diabetes mellitus.
Which of the following terms should the nurse use to begin each entry?
Data.
Problem.
Focus.
Assessment.
The Correct Answer is C
Focus.
Focus charting is a method of organizing health information in an individual’s record using nursing terminology to describe the individual’s health status and nursing actions. The focus of each entry can be a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a key word indicating compliance with a standard of care.
The focus charting method uses three columns: date and hour, focus, and progress notes. The progress notes are organized into data, action, and response, referred to as DAR.
Choice A is wrong because data is not the term used to begin each entry, but rather the category that describes the subjective and/or objective information supporting the stated focus. Choice B is wrong because problem is not the term used to begin each entry, but rather the nursing diagnosis or collaborative problem on the plan of care. Choice D is wrong because assessment is not the term used to begin each entry, but rather the phase of the nursing process that involves collecting data.
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Correct Answer is B
Explanation
“I should document any incident that occurs during my shift and notify the provider.” This statement indicates an understanding of the legal aspects of documentation, which include:.
• Documenting accurately, objectively, and completely to provide evidence of care delivery and support the nurse’s moral and legal responsibilities.
• Documenting any change in the patient’s condition, treatments, medications, interventions, client responses, and complaints.
• Documenting any incident that occurs during the shift and notifying the provider to ensure appropriate follow-up and prevent further harm.
• Documenting in a timely manner to minimize errors and omissions.
The other choices are wrong because:.
• Choice A is wrong because documenting only normal findings can mislead the client and other health professionals about the actual status of the client.It can also impede patient care and hinder the nurse’s legal defense in the event of a malpractice lawsuit.
• Choice C is wrong because documenting in advance can compromise the accuracy and integrity of the documentation.It can also lead to legal action if the documented events do not match the actual events.
• Choice D is wrong because documenting personal opinions about the client’s condition and care can be considered unprofessional, biased, and disrespectful.It can also damage the nurse-client relationship and expose the nurse to legal liability.
Normal ranges for documentation depend on the type of information being documented, such as vital signs, laboratory values, assessment findings, etc.
They may vary according to different sources and standards.
Nurses should follow the policies and procedures of their institution and use their clinical judgment when documenting abnormal findings.
Correct Answer is C
Explanation
It reduces duplication of documentation among caregivers.
This is an advantage of using an EHR system because it allows different healthcare providers to access and update the same record, avoiding unnecessary repetition and inconsistency.An EHR system also improves the quality and safety of care by providing clinical decision support, reducing medication errors, and facilitating communication among caregivers.
Choice A is wrong because it is not the only advantage of using an EHR system.While it is true that an EHR system eliminates errors due to illegible handwriting, it may also introduce new types of errors such as data entry mistakes, system failures, or unauthorized access.
Choice B is wrong because it is not an advantage of using an EHR system.
In fact, it may be a disadvantage because it poses a risk to the confidentiality and security of the clients’ records.An EHR system should have built-in safeguards to protect the privacy and integrity of the data, such as encryption, passwords, and audit trails.
Choice D is wrong because it is not an advantage of using an EHR system.It is a requirement of any health record system, whether electronic or paper-based, to comply with the ethical and legal standards of confidentiality.
An EHR system does not provide any additional safeguards that are not already present in a paper-based system.
Normal ranges for vital signs are as follows:.
• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).
• Pulse: 60 to 100 beats per minute.
• Respirations: 12 to 20 breaths per minute.
• Blood pressure: less than 120/80 mm Hg.
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