Documentation and Reporting
Documentation and Reporting ( 5 Questions)
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:.
Narrative charting is a type of documentation system that uses descriptive sentences or paragraphs to record patient information. Narrative charting is often time-consuming and may include irrelevant or redundant details.
Problem-oriented charting is a type of documentation system that organizes patient information around specific problems or diagnoses. Problem-oriented charting typically uses the SOAP format (subjective, objective, assessment, plan) or its variations (SOAPIE, SOAPIER) to document the patient’s status and progress.
Charting by exception is a type of documentation system that only records abnormal or significant findings or deviations from pre-established standards or norms. Charting by exception assumes that everything is normal unless otherwise documented.
This type of documentation system uses graphs, tables, or checklists to record data that can be easily visualized and compared over time. Flow sheet charting is especially useful for documenting vital signs, blood glucose levels, intake and output, and other routine or repetitive measurements.
Flow sheet charting.
This type of documentation system uses graphs, tables, or checklists to record data that can be easily visualized and compared over time. Flow sheet charting is especially useful for documenting vital signs, blood glucose levels, intake and output, and other routine or repetitive measurements.
Choice A is wrong because narrative charting is a type of documentation system that uses descriptive sentences or paragraphs to record patient information. Narrative charting is often time-consuming and may include irrelevant or redundant details.
Choice B is wrong because problem-oriented charting is a type of documentation system that organizes patient information around specific problems or diagnoses. Problem-oriented charting typically uses the SOAP format (subjective, objective, assessment, plan) or its variations (SOAPIE, SOAPIER) to document the patient’s status and progress.
Choice C is wrong because charting by exception is a type of documentation system that only records abnormal or significant findings or deviations from pre-established standards or norms. Charting by exception assumes that everything is normal unless otherwise documented.
Normal ranges for blood glucose levels are 70 to 130 mg/dL before meals and less than 180 mg/dL two hours after meals. Normal ranges for urine output are 0.5 to 1 mL/kg/hour for adults and 1 to 2 mL/kg/hour for children.