Documenting Nursing Activities (Record System Used in an Agency)
Documenting Nursing Activities (Record System Used in an Agency) ( 27 Questions)
A nurse is using the focus charting method to document care for a client who has diabetes mellitus.
Which of the following terms should the nurse use to begin each entry?
Data is not the term used to begin each entry, but rather the category that describes the subjective and/or objective information supporting the stated focus.
Problem is not the term used to begin each entry, but rather the nursing diagnosis or collaborative problem on the plan of care.
Focus charting is a method of organizing health information in an individual’s record using nursing terminology to describe the individual’s health status and nursing actions. The focus of each entry can be a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a key word indicating compliance with a standard of care.
The focus charting method uses three columns: date and hour, focus, and progress notes. The progress notes are organized into data, action, and response, referred to as DAR.
Assessment is not the term used to begin each entry, but rather the phase of the nursing process that involves collecting data.
Focus.
Focus charting is a method of organizing health information in an individual’s record using nursing terminology to describe the individual’s health status and nursing actions. The focus of each entry can be a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a key word indicating compliance with a standard of care.
The focus charting method uses three columns: date and hour, focus, and progress notes. The progress notes are organized into data, action, and response, referred to as DAR.
Choice A is wrong because data is not the term used to begin each entry, but rather the category that describes the subjective and/or objective information supporting the stated focus. Choice B is wrong because problem is not the term used to begin each entry, but rather the nursing diagnosis or collaborative problem on the plan of care. Choice D is wrong because assessment is not the term used to begin each entry, but rather the phase of the nursing process that involves collecting data.