Documentation System
Documentation System ( 5 Questions)
A nurse is preparing to document the care plan for a client who has a problem-oriented medical record (POMR).
Which of the following actions should the nurse take?
(Select all that apply.).
The nurse should not generate the care plan from the database, but rather from the problem list. The problem list is the centerpiece of the POMR and reflects the patient’s current health status and needs.
The nurse should number the care plan to correspond to the problem list and update the problem list as needed. These actions are consistent with the principles of the problem-oriented medical record (POMR), which is a method of organizing patient information by the health problems that require attention. The POMR includes a patient database, a problem list, a plan of care, and progress notes.
The nurse should not repeat assessments and interventions that apply to more than one problem, but rather use cross-referencing to avoid duplication and confusion.
The nurse should number the care plan to correspond to the problem list and update the problem list as needed. These actions are consistent with the principles of the problem-oriented medical record (POMR), which is a method of organizing patient information by the health problems that require attention. The POMR includes a patient database, a problem list, a plan of care, and progress notes.
The nurse should not use a standardized format for chart entries, but rather use a SOAP format (subjective, objective, assessment, plan) or a modified version of it (such as SOAPIE or SOAPIER) to document each problem and its progress.
The nurse should number the care plan to correspond to the problem list and update the problem list as needed. These actions are consistent with the principles of the problem-oriented medical record (POMR), which is a method of organizing patient information by the health problems that require attention. The POMR includes a patient database, a problem list, a plan of care, and progress notes.
Choice A is wrong because the nurse should not generate the care plan from the database, but rather from the problem list. The problem list is the centerpiece of the POMR and reflects the patient’s current health status and needs.
Choice C is wrong because the nurse should not repeat assessments and interventions that apply to more than one problem, but rather use cross-referencing to avoid duplication and confusion.
Choice E is wrong because the nurse should not use a standardized format for chart entries, but rather use a SOAP format (subjective, objective, assessment, plan) or a modified version of it (such as SOAPIE or SOAPIER) to document each problem and its progress.
The normal ranges for some common laboratory tests are:.
• CBC (complete blood count):.
➤ Hemoglobin: 13.5-17.5 g/dL (male), 12-16 g/dL (female).
➤ Hematocrit: 38.8-50% (male), 34.9-44.5% (female).
➤ White blood cell count: 4.5-11 x 10^9/L.
➤ Platelet count: 150-450 x 10^9/L.
• SMAC (sequential multiple analysis computer):.
➤ Sodium: 135-145 mEq/L.
➤ Potassium: 3.5-5 mEq/L.
➤ Chloride: 98-106 mEq/L.
➤ Bicarbonate: 22-29 mEq/L.
➤ Blood urea nitrogen: 7-20 mg/dL.
➤ Creatinine: 0.6-1.2 mg/dL (male), 0.5-1.1 mg/dL (female).
➤ Glucose: 70-110 mg/dL.
➤ Calcium: 8.5-10.2 mg/dL.
• EKG (electrocardiogram):.
➤ Heart rate: 60-100 beats per minute.