Which of these statements about documentation are true?
(Select all that apply.).
Documentation should be done as soon as possible after an event has occurred.
Documentation should include objective data, subjective data, and nursing interventions.
Documentation should use abbreviations, symbols, and acronyms that are approved by the facility.
Documentation should include opinions, judgments, and assumptions about the client’s condition.
Documentation should reflect the nursing process and the standards of care.
Correct Answer : A,B,C
Documentation should be done as soon as possible after an event has occurred, because this ensures accuracy, timeliness, and continuity of care. Documentation should include objective data (what the nurse observes or measures), subjective data (what the patient says or feels), and nursing interventions (what the nurse does or plans to do) to provide a clear picture of the patient’s condition and needs. Documentation should use abbreviations, symbols, and acronyms that are approved by the facility, because this promotes consistency, clarity, and compliance with legal and professional standards.
Choice D is wrong because documentation should not include opinions, judgments, or assumptions about the client’s condition, as these are not based on facts or evidence and may be biased or inaccurate. Documentation should be factual, accurate, and objective.
Choice E is wrong because documentation should reflect the nursing process and the standards of care, but this is not a complete statement. Documentation should also reflect the patient’s perspective, preferences, and goals. Documentation should be patient-centered, holistic, and individualized.
Normal ranges for clinical observations vary depending on the patient’s age, health status, and other factors.
However, some general ranges are:.
• Temperature: 36.5°C to 37.5°C.
• Pulse: 60 to 100 beats per minute.
• Respirations: 12 to 20 breaths per minute.
• Blood pressure: 120/80 mmHg or lower.
• Oxygen saturation: 95% or higher.
Sources:.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Subjective, Objective, Assessment, Plan.This is the meaning of SOAP format, which is a documentation method used by nurses and other healthcare providers to write out notes in the patient’s chart.
Choice B is wrong becauseSituation, Observation, Action, Problemis not a documentation method, but a communication tool used in handovers and briefings.
Choice C is wrong becauseSummary, Outcome, Analysis, Processis not a documentation method, but a framework for writing reflective essays.
Choice D is wrong becauseSource, Opinion, Accuracy, Purposeis not a documentation method, but a criteria for evaluating information sources.
SOAP format helps to organize the information collected from the patient in a clear and consistent manner.
It consists of four components:.
• Subjective: This includes how the patient is feeling and how they have been since the last review in their own words.
• Objective: This includes the objective observations that can be measured, seen, heard, felt or smelled, such as vital signs, fluid balance, clinical examination findings and investigation results.
• Assessment: This includes the thoughts on the salient issues and the diagnosis (or differential diagnosis) based on the subjective and objective data.
• Plan: This includes the actions that will be taken to address the patient’s problems, such as medications, investigations, referrals and follow-ups.
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