Which of these statements about documentation are true?

(Select all that apply.).

Focus.

Focus charting is a method of organizing health information in an individual’s record using nursing terminology to describe the individual’s health status and nursing actions.The focus of each entry can be a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a key word indicating compliance with a standard of care.

The focus charting method uses three columns: date and hour, focus, and progress notes.The progress notes are organized into data, action, and response, referred to as DAR.

Choice A is wrong because data is not the term used to begin each entry, but rather the category that describes the subjective and/or objective information supporting the stated focus.Choice B is wrong because problem is not the term used to begin each entry, but rather the nursing diagnosis or collaborative problem on the plan of care.Choice D is wrong because assessment is not the term used to begin each entry, but rather the phase of the nursing process that involves collecting data.

Documentation should be done as soon as possible after an event has occurred, because this ensures accuracy, timeliness, and continuity of care.Documentation should include objective data (what the nurse observes or measures), subjective data (what the patient says or feels), and nursing interventions (what the nurse does or plans to do) to provide a clear picture of the patient’s condition and needs.Documentation should use abbreviations, symbols, and acronyms that are approved by the facility, because this promotes consistency, clarity, and compliance with legal and professional standards.

Choice D is wrong because documentation should not include opinions, judgments, or assumptions about the client’s condition, as these are not based on facts or evidence and may be biased or inaccurate.Documentation should be factual, accurate, and objective.

Choice E is wrong because documentation should reflect the nursing process and the standards of care, but this is not a complete statement.Documentation should also reflect the patient’s perspective, preferences, and goals.Documentation should be patient-centered, holistic, and individualized.

Normal ranges for clinical observations vary depending on the patient’s age, health status, and other factors.

However, some general ranges are:.

• Temperature: 36.5°C to 37.5°C.

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: 120/80 mmHg or lower.

• Oxygen saturation: 95% or higher.

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