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Documentation and Reporting

  • Documentation is the process of recording the patient assessment data and the nursing care plan in a standardized format using appropriate terminology, abbreviations, symbols, and charts.

  • Reporting is the process of communicating the patient assessment data and the nursing care plan to other health care providers verbally or in writing.

  • The principles of documentation and reporting include accuracy, completeness, clarity, conciseness, timeliness, confidentiality, and accountability.

  • The methods of documentation and reporting include narrative notes, flow sheets, checklists, graphic records, care plans, incident reports, hand-off reports, progress notes, discharge summaries.

Questions on Documentation and Reporting

Correct Answer is D

Explanation

<p>The nurse should obtain information on the presence and quality of pedal pulses on both legs from the report, as this indicates the adequacy of blood circulation and perfusion to the lower extremities, which can be compromised by surgery, positioning, or complications such as thromboembolism or compartment syndrome.</p>

Correct Answer is C

Explanation

<p>This is an important information to obtain from the client, as it indicates that the client has angina pectoris, which is chest pain caused by reduced blood flow to the heart muscle. However, this is not an urgent finding that requires immediate reporting to the provider, as it shows that the chest pain is stable and responsive to nitroglycerin.</p>

Correct Answer is A

Explanation

<p>This is an incorrect instruction, as choosing a different finger for each test throughout the day can increase the risk of infection and pain. The client should rotate the testing sites within one finger or use alternate sites, such as the forearm or palm.</p>

<p>This is an incorrect action, as documenting the finding as an expected outcome implies that continuous bubbling in the water seal chamber is normal, which it is not. The nurse should document the finding as an abnormal finding and report it to the provider.</p>

<p>This is an incorrect statement, as deleting any entries made by other staff members is unethical and illegal, as it alters the original record and may affect the client&#39;s care or legal outcomes. The nurse should follow the facility&#39;s policy on correcting errors in documentation, which usu

<p>This is the client&#39;s blood type, which is compatible with any blood type for transfusion, as AB positive is the universal recipient. It is not a reason to report to the provider or stop the transfusion.</p>
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