The newly hired nurse is being oriented to the charting system ...

[asan beg]

The newly hired nurse is being oriented to the charting system used at the employing facility. The preceptor tells the nurse to find the nursing section of the client's record and document vital signs and AM care.
 
  The nurse recognizes the form of documentation used at this facility is which of the following? 1. Problem-oriented charting
  2. SOAP charting
  3. Source-oriented charting
  4. Fact-oriented charting

Question 2

The nurse is preparing to document the discharge of the client after the client has left. Which of the following is the proper discharge documentation?
 
  1. Discharged by wheelchair at 0945. Wife collected belongings.
  2. Discharged by wheelchair at 0945 accompanied by wife. Assisted into car. Client states he is ready to go home.
  3. Discharged by wheelchair to car with belongings.
  4. Discharged by wheelchair at 0945.

[Fayaz00962]

Answer to Question 1

3
Rationale: In source charting, each discipline has its own area in the client record for charting. SOAP is a method of charting narrative interventions. Problem-oriented records are charted by each discipline according to the client problems. FACT charting uses a system of flow sheets that are individualized for the client.

Answer to Question 2

2
Rationale: When documenting a discharge, the nurse charts how the client was discharged, with whom the client was discharged, and how the client tolerated the procedure.

[asan beg]

Both answers were spot on, thank you once again

[Fayaz00962]

Great! Please up vote