Information and Documentation: 4 Questions

Question 1

what is it where you “chart physiological data/routine care to see trends”?

Answer 1

Flow sheets

Question 2

what documentation method is where it is “within normal limits unless documented otherwise (abnormal findings)”?

Answer 2

Charting by exception

Question 3

what documentation method is where the “record progress toward resolving patient issues”?

Answer 3

progress notes

Question 4

what documentation is where it is “comprehensive admission assessment”?

Answer 4

Admission Nursing History Form

Question 5

what documentation is where it is “summary of care provided/used in shift reports”?

Answer 5

Patient Care Summary

Question 6

what documentation is where it is “standardized care plans or clinical practice guidelines”?

Answer 6

care plans

Question 7

what documentation is where it is “summary of discharge instructions/information”?

Answer 7

discharge summery forms

Question 8

Failing to report nursing actions, pertinent or relevant health or dug information, medication administration, drug reactions or changes in person’s conditions, incomplete records, discontinued medications which can lead to what?

Answer 8

complications or malpractice