Exam 7: Documentation of Nursing Care

When the nurse charts in narrative or source-oriented format about the patient's condition and the nursing care provided, it is appropriate for him to record:

A clinic nurse is documenting in a patient chart about the pain that brought the patient to seek medical attention. The best description is:

Charting that follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses' progress notes is _______ charting.

A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to have the medical chart to take, because it is her personal property. An appropriate response would be:

In an agency that uses specific protocols (Standard Procedures) and charting by exception, an advantage compared with using traditional (narrative or problem-oriented) charting is that charting by exception:

The nurse understands that a face sheet contains information pertaining to:

The nurse explains that should a patient return to the hospital for treatment within _______ years, the medical chart can be retrieved from medical records for review.

A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced by disruption of skin surface has the following nursing documentation: "Incision clean, dry, intact. No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from clothing. Verbalizes understanding of wound care and ability to manage at home. Wound healing without complication." This documentation is: