Exam 4: Reporting and Recording

__________________ documentation should include your observations of patient behavior.

The documentation method that focuses on the patient's problems is known as:

The patient was in bed with all side rails up.During the night,the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails.After meeting the patient's needs and assessing that the patient is not harmed,the nurse needs to:

Standardized Care Plans are effective ways to plan care for the patient.To be most effective,however,the SCP must be _________________.

A mistake is made when the patient's vital signs are recorded on a flow sheet.The nurse should:

The patient is ready to go home from the hospital.Prior to his leaving,the nurse provides the patient and family with a:

The patient is on a medical unit.Any changes in the patient's condition can be compared with data found on the _______________.

The nursing assistant tells the RN that when the patient's vital signs were taken,the patient complained that she was in a lot of pain.The nursing assistant then tells the nurse that she charted the patient's complaint when she charted the vital signs.The nurse needs to instruct the nursing assistant that:

A preprinted guideline used to care for patients with similar health problems is known as:

Patients on the unit have their vital signs taken routinely at 0800,1200,1600,and 2000.At 1000,a patient complains of feeling "light headed." The nurse takes the patient's vital signs and finds blood pressure to be lower than usual.Within 15 minutes,the patient says that he feels better.The nurse rechecks the blood pressure and finds that it is now back to normal.The nurse should:

________________ provide a quick,easy reference for health care team members in assessing the patient's status.

Discharge planning achieves specific outcomes that include: (Select all that apply.)

Nursing documentation: (Select all that apply.)

___________________ begins at admission and becomes a more prominent part of care as the patient gets closer to discharge.

The traditional method for recording nursing care and activities,which uses a story-like format usually in chronological order,is known as ______________.

A student nurse notes that space is left after an entry on the patient's narrative note.The student should:

Current Joint Commission standards require that ______ patients who are admitted to a health care institution have an assessment of physical,psychosocial,environmental,self-care,patient education,and discharge planning needs.

Nursing documentation must have the following characteristics.It must be: (Select all that apply.)

The patient has been in the hospital for a hip replacement.According to his critical pathway,he should have his Foley catheter discontinued on the fourth day after surgery.Instead,the patient has it removed on the third day and is voiding normally with no problems.This would be a sign of:

Which of the following is the best example of accurate documentation?