A nurse is using focus charting to document a client’s progress notes.

What are the advantages of using focus charting?

(Select all that apply.).

It highlights the client’s concerns and strengths.

It reduces redundancy and duplication of data.

It facilitates communication among health care team members.

It incorporates nursing diagnoses and care plans.

It provides a chronological record of events.

Answer and Explanation

Correct Answer : A,B,C

Focus charting is a method of organizing health information in an individual’s record that centers on the patient’s concerns and strengths. It uses a three-column format to document the data, action and response (DAR) of each focus.

The advantages of using focus charting are:.

• It highlights the client’s concerns and strengths, which makes the care more patient-centered and holistic.

• It reduces redundancy and duplication of data, as it avoids repeating information that is already recorded in other forms or flow sheets.

• It facilitates communication among health care team members, as it promotes interdisciplinary documentation and helps organize the information in a concise and precise way.

Choice D is wrong because focus charting does not incorporate nursing diagnoses and care plans, although it is based on the nursing process. Nursing diagnoses and care plans are documented separately or as part of the action category.

Choice E is wrong because focus charting does not provide a chronological record of events, but rather organizes the data by the focus. A chronological record of events can be found in other forms of documentation, such as narrative or SOAP notes.

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Correct Answer is ["A","B"]

Explanation

These are the only options that describe thesubjectiveandobjectivedata of the patient, which are part of theSOAPdocumentation method.SOAP stands forSubjective, Objective, Assessment, and Plan, and it is a way of recording patient data in a clear and consistent manner.

ChoiceCis wrong because wound culture results are not part of the assessment entry in SOAP documentation.They are part of the investigation results, which are usually documented in the objective section.

ChoiceDis wrong because risk for infection related to impaired skin integrity is a nursing diagnosis, not an assessment.Nursing diagnoses are usually documented in the plan section of SOAP documentation.

ChoiceEis wrong because applied moist heat compresses to the wound site is an intervention, not an assessment.Interventions are also documented in the plan section of SOAP documentation.

Normal ranges for vital signs are as follows:.

• Blood pressure: 90/60 mmHg to 120/80 mmHg.

• Pulse rate: 60 to 100 beats per minute.

• Respiratory rate: 12 to 20 breaths per minute.

• SpO2: 95% to 100%.

• Temperature: 36.5°C to 37.5°C.

A. Use a personal password to access the system and log off when finished. B. Share the password with other nurses who need to access the system. C. Print out a copy of the client’s record and store it in a locked cabinet. D. Report any breaches or attempted breaches of security to the appropriate personnel. E. Delete any information that is incorrect or outdated from the system.

Correct Answer is ["A","D"]

Explanation

The nurse should use a personal password to access the system and log off when finished, and report any breaches or attempted breaches of security to the appropriate personnel.

These actions ensure confidentiality and security of the client’s information by preventing unauthorized access and disclosing any violations.

Choice B is wrong because sharing the password with other nurses who need to access the system violates the principle ofminimum necessary access, which means that only those who need the information for a specific purpose should have access to it.

Choice C is wrong because printing out a copy of the client’s record and storing it in a locked cabinet creates a risk ofloss, theft, or unauthorized disclosureof the paper record.The nurse should avoid printing out electronic health records unless absolutely necessary, and should follow the proper disposal procedures if they do.

Choice E is wrong because deleting any information that is incorrect or outdated from the system may compromise theintegrity and availabilityof the client’s information.The nurse should follow the established policies and procedures for correcting or updating electronic health records, which may include adding an addendum or annotation to the original entry, but not deleting it.

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A nurse is using focus charting to document a client’s progress notes. What are the advantages of using focus charting? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg. The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.

Correct Answer is ["A","B"]

Explanation

A nurse is working in an agency that uses EHR for documentation. Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information? (Select all that apply.).

Correct Answer is ["A","D"]

Explanation

A nurse is preparing to document the admission nursing assessment for a client who has pneumonia. Which of the following information should the nurse include in this documentation?

A nurse is teaching a newly hired nurse about the legal aspects of documentation. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

A nurse is using focus charting to document a client’s progress notes. What are the advantages of using focus charting? (Select all that apply.).

A nurse is documenting the care provided to a client who receives home health services. Which of the following records should the nurse use to certify that the client meets Medicare eligibility criteria and to outline the services to be provided?

A nurse is using an electronic health record (EHR) system to document care for a client who has pneumonia. Which of the following is an advantage of using an EHR system?

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.).

A nurse is reviewing a critical pathway for a client who has chronic obstructive pulmonary disease (COPD). The nurse should understand that a critical pathway:.

A nurse is using focus charting to document a client’s progress notes.

What are the advantages of using focus charting?

(Select all that apply.).