A nurse is documenting client care including only unexpected findings related to the client's condition.
Which of the following documentation methods is the nurse utilizing?

Charting by exception (CBE).

Focus charting (DAR).

Problem-oriented medical record (POMR).

SOAP documentation.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Charting by exception (CBE) is a documentation method in which the nurse documents only unexpected findings or significant deviations from the client's normal condition. It is based on the assumption that the client's baseline status remains within the expected range, and deviations from this norm are documented. CBE is efficient and allows nurses to focus on relevant and critical information, reducing unnecessary documentation. It is particularly useful in clinical settings where frequent assessments are needed.

Choice B rationale:

Focus charting (DAR) is another method of documenting client care that emphasizes a structured approach to documentation, with a focus on data, action, and response (DAR). While it provides a systematic way to document care, it does not necessarily limit documentation to only unexpected findings. Focus charting encourages documentation of care in a problem-oriented manner, which may include expected or routine assessments.

Choice C rationale:

Problem-oriented medical record (POMR) is a documentation system that focuses on organizing client information around specific healthcare problems or diagnoses. It encourages a problem-solving approach to care and promotes the inclusion of a comprehensive client history and care plan. POMR documentation may involve both expected and unexpected findings, so it does not limit documentation to only unexpected findings.

Choice D rationale:

SOAP documentation stands for Subjective, Objective, Assessment, and Plan. It is a structured method of documenting healthcare encounters. SOAP notes include a wide range of information, including both subjective (patient's description of symptoms) and objective (clinician's observations) data. While SOAP notes are organized, they do not specifically limit documentation to only unexpected findings.

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Correct Answer is D

Explanation

The correct answer is Choice D: Obtaining a blood pressure for a client who is to be discharged later in the day.

Choice A rationale:

Providing tracheostomy care requires specialized training and assessment skills, which are beyond the scope of practice for assistive personnel (AP).

Choice B rationale:

Assessing a client who just returned from surgery involves clinical judgment and decision-making, which are responsibilities of a licensed nurse, not assistive personnel.

Choice C rationale:

Teaching a client how to use an incentive spirometer requires patient education skills and the ability to assess the client's understanding, which are tasks for a licensed nurse.

Choice D rationale:

Obtaining a blood pressure is a routine task that can be delegated to assistive personnel, as it does not require advanced clinical judgment or specialized training.

A. Include a note in the medical record that an incident report was completed. B. Identify other people involved with the event in the incident report. C. Include personal opinions regarding an event in an incident report. D. Identify the person responsible for the error in the incident report.

Correct Answer is B

Explanation

Choice A rationale:

Including a note in the medical record that an incident report was completed is a crucial step in documenting the event. It serves as a legal and organizational record of the incident, providing transparency and accountability. This information can be essential for tracking trends, identifying areas for improvement, and ensuring patient safety.

Choice B rationale:

Identifying other people involved with the event in the incident report is also an important step. It helps in determining who was present or responsible during the incident, which can be crucial in investigating the event and identifying potential areas for process improvement.

Choice C rationale:

Including personal opinions regarding an event in an incident report is not advisable. Incident reports should focus on factual, objective information. Personal opinions can introduce bias and subjectivity, which may not be helpful in addressing the root causes of the incident or improving the quality of care.

Choice D rationale:

Identifying the person responsible for the error in the incident report is a valid step, as it helps in assigning accountability and addressing any systemic issues that may have contributed to the error. However, it's essential to do so without assigning blame or making judgments. The emphasis should be on improving processes and preventing similar incidents in the future.

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A nurse is documenting client care including only unexpected findings related to the client's condition.Which of the following documentation methods is the nurse utilizing?

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A nurse is documenting client care including only unexpected findings related to the client's condition.
Which of the following documentation methods is the nurse utilizing?