Documentation and Reporting

A nurse is caring for a patient who has a history of depression and is taking an antidepressant medication.

The nurse asks the patient how he is feeling today.

The patient responds: “I don’t know, I guess I’m okay.” Which of the following statements by the nurse is an appropriate response?

A nurse is documenting the care provided to a patient who has a wound infection.

The nurse writes: “The wound was cleansed with normal saline and covered with a sterile dressing.

No signs of redness, swelling, or drainage were noted.” Which of the following statements reflects the nurse’s use of objective data?

A nurse is using a computer-based system to document the care provided to a patient who has diabetes mellitus.

The nurse enters the patient’s blood glucose level, insulin dose, dietary intake, and urine output.

The system automatically generates a graph that shows the trends and patterns of these data over time.

This type of documentation system is known as:.

A nurse is preparing to report the status of a patient to another nurse during a shift change.

The nurse should include which of the following information in the report?

(Select all that apply.).

A nurse is reviewing the documentation and reporting policies of a healthcare facility.

The nurse understands that documentation serves as a permanent record of patient information, data, and care.

Which of the following is another purpose of documentation?