Exam 16: Documenting and Reporting

A nurse works in a hospital that utilises a charting by exception documentation system. When providing care and performing assessments, the nurse may not address all of the sections on a client's flow sheet, especially if the client did not require this particular care. In order for the nurse to identify that these areas were addressed, but no care was needed, the best action is to:

The use of abbreviations is limited because:

The client, after receiving emergency treatment for an acute asthma attack, had diminished wheezing in both lungs. When utilising focus charting, this information would be included in the ________ section.

The client states: "I really don't want anyone to visit me who has not been approved by me first". If utilising SOAP format, this statement would be documented under which category?

A student nurse is reviewing an assigned client's chart. When trying to locate recent lab results, the student notices that each department has a separate section in the chart. This type of documentation system is called which of the following?

A client has specific cultural needs in regard to the plan of care. The facility uses narrative charting. This information would be found in which of the following?