Exam 15: Documenting and Reporting

The client states: "I really don't want anyone to visit me who has not been cleared by me first." If utilizing SOAP format,in which category should the nurse document this statement?

The nurse makes chronological entries in a client's chart that include documentation about the routine care provided,assessment findings,and client problems during a 12-hour shift.Which type of charting is this nurse completing?

When responding to a call light,the nurse finds a client lying on the floor,with the bed linens around the legs.Which chart entry should the nurse document for this finding?

A cardiac specialty hospital has several written plans in place for clients who are admitted,according to specific medical diagnoses and nursing interventions.Typical nursing diagnoses as well as standard nursing interventions are included in these plans.Which type of form is this hospital utilizing?