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.
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 A
Explanation
Choice A rationale:
In the SOAP charting model, the subjective component is where the client's subjective information and feelings are documented. This includes the client's own reports of symptoms, sensations, and experiences. In this case, the client reporting chest pain after mowing the lawn this morning is a subjective statement made by the client. This information is valuable as it provides insight into the client's perception of their condition and helps healthcare providers understand their symptoms and experiences.
Choice B rationale:
The blood pressure reading (182/98 mm Hg) is an objective measurement, not a subjective statement from the client. Objective data includes measurable and observable information, like vital signs, lab results, and physical examination findings. This type of information is typically documented in the objective component of SOAP charting.
Choice C rationale:
The administration of nitroglycerin (0.3 mg SL) is also an objective action taken by the client, not a subjective statement. It falls under the plan section of the SOAP chart, where healthcare providers outline the actions or interventions taken.
Choice D rationale:
The description of the client's skin (pale and diaphoretic) is also objective data. It represents observable physical signs and is not part of the subjective component, which focuses on the client's own statements and feelings.
Correct Answer is A
Explanation
Choice A rationale:
Systematic reviews are considered Level I evidence in the hierarchy of evidence in evidence-based practice (EBP). Systematic reviews involve the rigorous and comprehensive synthesis of multiple research studies on a specific topic. This approach minimizes bias and provides the highest level of evidence for making clinical decisions. Systematic reviews typically follow a structured methodology and offer a critical analysis of the existing literature, making them a strong foundation for EBP.
Choice B rationale:
Credible websites are not considered Level I evidence. While some websites may contain reliable information, they vary in quality, and the credibility of the source must be carefully assessed. Relying solely on websites is not the most robust approach in EBP, as it lacks the rigorous systematic review and critical appraisal process of Level I evidence.
Choice C rationale:
Expert opinions are not considered Level I evidence. While expert opinions can be valuable, they are often based on individual experiences and interpretations rather than systematic research. Expert opinions are generally considered lower in the hierarchy of evidence compared to systematic reviews and other forms of research evidence.
Choice D rationale:
Qualitative studies are not considered Level I evidence. Qualitative studies provide valuable insights into the experiences, perceptions, and meanings associated with a particular phenomenon. However, they are typically ranked lower in the hierarchy of evidence compared to systematic reviews and quantitative research studies. Qualitative studies are more appropriate for addressing research questions related to subjective experiences and understanding the "why" and "how" of a phenomenon.
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