When recording data regarding the client's health record, the ...

[V@ndy87]

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client.
 
  Which of the following styles of documentation is the nurse implementing? A) Focus charting
  B) SOAP charting
  C) PIE charting
  D) Narrative charting

Question 2

A client had a total knee replacement performed 3 days ago and is now preparing for discharge home. What discharge teaching should the nurse provide to this client? Select all that apply.
 
  A) Guidelines for safely resuming normal activities
  B) Potential side effects of prescribed medications
  C) Information about the signs and symptoms of infection
  D) Information about follow-up appointments that may be required
  E) The importance of leg exercises and deep breathing and coughing

[Ashley I]

Answer to Question 1

B
Feedback:
The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

Answer to Question 2

A, B, C, D
Feedback:
Discharge teaching should encompass many areas of relevance to the client's recovery, including signs of complications, drug information, follow-up, and activity guidelines. Deep breathing and coughing as well as leg exercises are more significant during the immediate postoperative period rather than after discharge.