Documenting Nursing Activities (Record System Used in an Agency)
Documenting Nursing Activities (Record System Used in an Agency) ( 27 Questions)
A nurse is reviewing the record system used in an agency.
Which of the following types of records are used for documenting concise data about a client and making information quickly accessible to all health professionals?
(Select all that apply.).
Kardexes and flow sheets are types of records that are used for documenting concise data about a client and making information quickly accessible to all health professionals. Kardexes are a series of cards kept in a portable index file or on computer generated forms that contain a problem list, stated goals and list of nursing approaches to meet the goals. Flow sheets are forms that allow for recording routine aspects of care such as vital signs, intake and output, medications, etc.
Kardexes and flow sheets are types of records that are used for documenting concise data about a client and making information quickly accessible to all health professionals. Kardexes are a series of cards kept in a portable index file or on computer generated forms that contain a problem list, stated goals and list of nursing approaches to meet the goals. Flow sheets are forms that allow for recording routine aspects of care such as vital signs, intake and output, medications, etc.
Progress notes are not concise, but rather narrative descriptions of the client’s condition, interventions and outcomes.
Nursing discharge summaries are not used for quick access, but rather for providing information about the client’s hospitalization, treatment and follow-up care.
Care plan conferences are not records, but meetings where health professionals discuss the client’s needs, goals and progress.
Kardexes and flow sheets are types of records that are used for documenting concise data about a client and making information quickly accessible to all health professionals. Kardexes are a series of cards kept in a portable index file or on computer generated forms that contain a problem list, stated goals and list of nursing approaches to meet the goals. Flow sheets are forms that allow for recording routine aspects of care such as vital signs, intake and output, medications, etc.
Choice C is wrong because progress notes are not concise, but rather narrative descriptions of the client’s condition, interventions and outcomes. Choice D is wrong because nursing discharge summaries are not used for quick access, but rather for providing information about the client’s hospitalization, treatment and follow-up care. Choice E is wrong because care plan conferences are not records, but meetings where health professionals discuss the client’s needs, goals and progress.
Normal ranges for vital signs are as follows:.
• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).
• Pulse: 60 to 100 beats per minute.
• Respiration: 12 to 20 breaths per minute.
• Blood pressure: less than 120/80 mmHg.