A nurse is reviewing the record system used in an agency.

Which of the following types of records are used for documenting concise data about a client and making information quickly accessible to all health professionals?

(Select all that apply.).

Kardexes and flow sheets are types of records that are used for documenting concise data about a client and making information quickly accessible to all health professionals.Kardexes are a series of cards kept in a portable index file or on computer generated forms that contain a problem list, stated goals and list of nursing approaches to meet the goals.Flow sheets are forms that allow for recording routine aspects of care such as vital signs, intake and output, medications, etc.

Choice C is wrong because progress notes are not concise, but rather narrative descriptions of the client’s condition, interventions and outcomes.Choice D is wrong because nursing discharge summaries are not used for quick access, but rather for providing information about the client’s hospitalization, treatment and follow-up care.Choice E is wrong because care plan conferences are not records, but meetings where health professionals discuss the client’s needs, goals and progress.

Normal ranges for vital signs are as follows:.

• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).

• Pulse: 60 to 100 beats per minute.

• Respiration: 12 to 20 breaths per minute.

• Blood pressure: less than 120/80 mmHg.

“I should document any incident that occurs during my shift and notify the provider.” This statement indicates an understanding of the legal aspects of documentation, which include:.

• Documenting accurately, objectively, and completely to provide evidence of care delivery and support the nurse’s moral and legal responsibilities.

• Documenting any change in the patient’s condition, treatments, medications, interventions, client responses, and complaints.

• Documenting any incident that occurs during the shift and notifying the provider to ensure appropriate follow-up and prevent further harm.

• Documenting in a timely manner to minimize errors and omissions.

The other choices are wrong because:.

• Choice A is wrong because documenting only normal findings can mislead the client and other health professionals about the actual status of the client.It can also impede patient care and hinder the nurse’s legal defense in the event of a malpractice lawsuit.

• Choice C is wrong because documenting in advance can compromise the accuracy and integrity of the documentation.It can also lead to legal action if the documented events do not match the actual events.

• Choice D is wrong because documenting personal opinions about the client’s condition and care can be considered unprofessional, biased, and disrespectful.It can also damage the nurse-client relationship and expose the nurse to legal liability.

Normal ranges for documentation depend on the type of information being documented, such as vital signs, laboratory values, assessment findings, etc.

They may vary according to different sources and standards.

Nurses should follow the policies and procedures of their institution and use their clinical judgment when documenting abnormal findings.