Answer to Question 1
D
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Progress records describe the treatment and responses of the client. Assessment documents record all client information. Minimum data sets and resident assessment protocols guide nurses to develop individualized care plans, especially in long-term and home care. Plans for treatment of the client include the physician's orders and the nursing care plan.
Answer to Question 2
C
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A resident assessment protocol, or RAP, will help the nurse in identifying functional losses affecting the client's ability to perform activities of daily living. An MIS or medical information system is used for storing, processing, and transmitting client data, treatment strategies, and outcomes over a computer network. It is a method for keeping electronic records. A medication administration record, or MAR, is a progress record that lists all medications that the physician has ordered for the client, with spaces for the caregiver to mark when medications are given. Charting by exception, or CBE, is a system that uses a flow sheet that identifies excepted assessments, and a progress note to identify abnormalities or unexpected findings.
Patients with physical special needs, such as a wheelchair, need to have this documented in their he
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