Documenting Nursing Activities (Record System Used in an Agency)
Documenting Nursing Activities (Record System Used in an Agency) ( 27 Questions)
A nurse is using CBE documentation for a client who has diabetes mellitus.
The nurse administers insulin to the client and documents this on a:.
a graphic record is a document that shows the trends of vital signs, intake and output, weight, and other measurements over time.
A graphic record does not include information about medications.
A daily care record is a document that records the routine care activities that have been performed for a patient, such as hygiene, nutrition, elimination, mobility, and comfort measures.
A daily care record does not include information about medications.
A medication administration record (MAR) is a document that records the medications that have been given to a patient, including the dose, route, time, and nurse’s initials.
A MAR is an essential part of nursing documentation and ensures safe and accurate medication administration.
Choice A is wrong because a graphic record is a document that shows the trends of vital signs, intake and output, weight, and other measurements over time.
A graphic record does not include information about medications.
A client teaching record is a document that records the education that has been provided to a patient or family, such as disease process, medications, diet, exercise, self-care, and discharge planning.
A client teaching record does not include information about medication administration.
Medication administration record.
A medication administration record (MAR) is a document that records the medications that have been given to a patient, including the dose, route, time, and nurse’s initials.
A MAR is an essential part of nursing documentation and ensures safe and accurate medication administration.
Choice A is wrong because a graphic record is a document that shows the trends of vital signs, intake and output, weight, and other measurements over time.
A graphic record does not include information about medications.
Choice B is wrong because a daily care record is a document that records the routine care activities that have been performed for a patient, such as hygiene, nutrition, elimination, mobility, and comfort measures.
A daily care record does not include information about medications.
Choice D is wrong because a client teaching record is a document that records the education that has been provided to a patient or family, such as disease process, medications, diet, exercise, self-care, and discharge planning.
A client teaching record does not include information about medication administration.
CBE documentation is a method of charting by exception that allows the nurse to document only those findings that fall outside the standard of care or norms defined by a specific institution.
CBE documentation reduces the amount of time required to document care and eliminates unnecessary or redundant information.
However, CBE documentation does not apply to medication administration, which must be documented accurately and completely for every patient.