The nurse managers of a home health care office wish to maximize ...

[captainjonesify]

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
 
  A) Narrative notes
  B) SOAP notes
  C) Focus charting
  D) Charting by exception

Question 2

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks?
 
  A) Vulnerability to legal liability since nurse's safe, routine care is not recorded
  B) Increased workload for nurses in order to complete necessary documentation
  C) Failure to identify and record client problems and associated interventions
  D) Significant differences in the charting between nurses due to lack of standardization

[bookworm410]

Answer to Question 1

Ans: A

One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

Answer to Question 2

Ans: A

A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

[captainjonesify]

Excellent

[epscape]

Gracias!