When the nurse charts only additional treatments done, abnormal findings, changes in patient condition, and new concerns, the system of documentation is:

Choice A rationale

An incident report primarily focuses on documenting the facts of an event, not on preventing lawsuits. While a thorough report might indirectly help in legal defense by providing a clear record, its main purpose isn't legal protection. Legal strategies are separate from the incident reporting process.

Choice B rationale

Incident reports are crucial for a healthcare facility's quality improvement initiatives. By systematically documenting occurrences like patient falls, the hospital can analyze trends, identify potential risks and contributing factors, and implement strategies to prevent similar incidents in the future, thereby enhancing patient safety and care quality.

Choice C rationale

While incident reports from various units might be reviewed and compared as part of a broader quality improvement effort, the primary reason for completing an individual incident report is not solely for comparing fall rates between units. The immediate goal is to document the specific incident and identify local contributing factors.

Choice D rationale

Incident reports are designed to document events objectively. They are not primarily used as a basis for disciplinary action against a nurse. Disciplinary processes would involve a separate investigation to determine if negligence or policy violations occurred, based on various sources of information, not just the incident report.

Choice A rationale

SBAR (Situation, Background, Assessment, Recommendation) is a structured communication tool used for verbal or written reports, focusing on concise information transfer during transitions of care or urgent situations, not a comprehensive charting system based on exceptions.

Choice B rationale

Focused charting centers on specific patient problems or concerns, using a DAR (Data, Action, Response) format. It addresses particular issues in detail rather than documenting only deviations from the norm.

Choice C rationale

Charting by exception (CBE) is a documentation system where nurses only document findings that are outside the normal range or significant changes in a patient's condition. Standardized care and expected outcomes are assumed to be met and are not routinely documented, saving time and reducing redundancy.

Choice D rationale

SOAP (Subjective, Objective, Assessment, Plan) is a problem-oriented charting method commonly used by physicians and other healthcare providers to organize patient information around specific problems identified during assessment.