Documenting Nursing Activities (Record System Used in an Agency)
Documenting Nursing Activities (Record System Used in an Agency) ( 27 Questions)
Which of these statements about documentation are true?
(Select all that apply.).
This ensures accuracy, timeliness, and continuity of care. Documentation should include objective data (what the nurse observes or measures), subjective data (what the patient says or feels), and nursing interventions (what the nurse does or plans to do) to provide a clear picture of the patient’s condition and needs. Documentation should use abbreviations, symbols, and acronyms that are approved by the facility, because this promotes consistency, clarity, and compliance with legal and professional standards.
This ensures accuracy, timeliness, and continuity of care. Documentation should include objective data (what the nurse observes or measures), subjective data (what the patient says or feels), and nursing interventions (what the nurse does or plans to do) to provide a clear picture of the patient’s condition and needs. Documentation should use abbreviations, symbols, and acronyms that are approved by the facility, because this promotes consistency, clarity, and compliance with legal and professional standards.
This ensures accuracy, timeliness, and continuity of care. Documentation should include objective data (what the nurse observes or measures), subjective data (what the patient says or feels), and nursing interventions (what the nurse does or plans to do) to provide a clear picture of the patient’s condition and needs. Documentation should use abbreviations, symbols, and acronyms that are approved by the facility, because this promotes consistency, clarity, and compliance with legal and professional standards.
Documentation should not include opinions, judgments, or assumptions about the client’s condition, as these are not based on facts or evidence and may be biased or inaccurate. Documentation should be factual, accurate, and objective.
Documentation should reflect the nursing process and the standards of care, but this is not a complete statement. Documentation should also reflect the patient’s perspective, preferences, and goals. Documentation should be patient-centered, holistic, and individualized.
Documentation should be done as soon as possible after an event has occurred, because this ensures accuracy, timeliness, and continuity of care. Documentation should include objective data (what the nurse observes or measures), subjective data (what the patient says or feels), and nursing interventions (what the nurse does or plans to do) to provide a clear picture of the patient’s condition and needs. Documentation should use abbreviations, symbols, and acronyms that are approved by the facility, because this promotes consistency, clarity, and compliance with legal and professional standards.
Choice D is wrong because documentation should not include opinions, judgments, or assumptions about the client’s condition, as these are not based on facts or evidence and may be biased or inaccurate. Documentation should be factual, accurate, and objective.
Choice E is wrong because documentation should reflect the nursing process and the standards of care, but this is not a complete statement. Documentation should also reflect the patient’s perspective, preferences, and goals. Documentation should be patient-centered, holistic, and individualized.
Normal ranges for clinical observations vary depending on the patient’s age, health status, and other factors.
However, some general ranges are:.
• Temperature: 36.5°C to 37.5°C.
• Pulse: 60 to 100 beats per minute.
• Respirations: 12 to 20 breaths per minute.
• Blood pressure: 120/80 mmHg or lower.
• Oxygen saturation: 95% or higher.
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