Documentation and Reporting
Documentation and Reporting ( 5 Questions)
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.).
The nurse should include the patient’s name, age, and diagnosis, the patient’s current vital signs and pain level, the patient’s preferences and goals for care, and the patient’s plan of care and any pending interventions in the report.
These are the most relevant and important information that the oncoming nurse needs to know to provide safe and effective care for the patient.
The nurse should include the patient’s name, age, and diagnosis, the patient’s current vital signs and pain level, the patient’s preferences and goals for care, and the patient’s plan of care and any pending interventions in the report.
These are the most relevant and important information that the oncoming nurse needs to know to provide safe and effective care for the patient.
The nurse should include the patient’s name, age, and diagnosis, the patient’s current vital signs and pain level, the patient’s preferences and goals for care, and the patient’s plan of care and any pending interventions in the report.
These are the most relevant and important information that the oncoming nurse needs to know to provide safe and effective care for the patient.
The patient’s family history and social support are not essential to include in the report.
They may be part of the patient’s medical record, but they are not likely to change during the shift or affect the patient’s immediate needs.
A nursing shift report is a document that a nurse writes about their patients at the end of their shift to give to the nurse tending to their patients on the next shift.
It helps the oncoming nurse understand the patient’s medical conditions, needs, and progress. It also helps ensure continuity of care and prevent errors or omissions.
The nurse should include the patient’s name, age, and diagnosis, the patient’s current vital signs and pain level, the patient’s preferences and goals for care, and the patient’s plan of care and any pending interventions in the report.
These are the most relevant and important information that the oncoming nurse needs to know to provide safe and effective care for the patient.
The nurse should include the patient’s name, age, and diagnosis, the patient’s current vital signs and pain level, the patient’s preferences and goals for care, and the patient’s plan of care and any pending interventions in the report.
These are the most relevant and important information that the oncoming nurse needs to know to provide safe and effective care for the patient.
Choice D is wrong because the patient’s family history and social support are not essential to include in the report.
They may be part of the patient’s medical record, but they are not likely to change during the shift or affect the patient’s immediate needs.
A nursing shift report is a document that a nurse writes about their patients at the end of their shift to give to the nurse tending to their patients on the next shift.
It helps the oncoming nurse understand the patient’s medical conditions, needs, and progress. It also helps ensure continuity of care and prevent errors or omissions.
Normal ranges for vital signs vary depending on age, gender, and health status, but generally they are:.
• Temperature: 36.5°C to 37.2°C (97.7°F to 99°F).
• Pulse: 60 to 100 beats per minute.
• Respiration: 12 to 20 breaths per minute.
• Blood pressure: less than 120/80 mmHg.
• Pain level: 0 to 10 on a numerical scale or using a visual analog scale.