The nurse records this entry in a patient's progress notes:
Patient escorted to unit by ER nurse at 2130. Patient's clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, Let me out of here. Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation.
How should this documentation be evaluated?
a. Uses unapproved abbreviations
b. Contains subjective material
c. Too brief to be of value
d. Excessively wordy
e. Meets standards
Question 2
A nurse prepares to assess a new patient who moved to the United States from Central America three years ago. After introductions, what is the nurse's next comment?
a. How did you get to the United States?
b. Would you like for a family member to help you talk with me?
c. An interpreter is available. Would you like for me to make a request for these services?
d. Are you comfortable conversing in English, or would you prefer to have a translator present?
A computerized patient registration form used by offices with electronic health records.
Comparison of Paper Medical Records and Electronic Health Records
Positioning the Patient in the Prone Position
Amyloid plaques (stained blue) in the brain of a deceased patient who had Alzheimer’s disease.
Ex vivo and in vivo gene therapy for a patient with a liver disorder