A nurse is charting. Which information is critical for the nurse ...

[Pineapplelove6]

A nurse is charting. Which information is critical for the nurse to document?
 
  a. The patient had a good day with no complaints.
  b. The family is demanding and argumentative.
  c. The patient received a pain medication, Lortab.
  d. The family is poor and had to go on welfare.

Question 2

A nurse developed the following discharge summary sheet. Which critical information should the nurse add?
 
  TOPIC DISCHARGE SUMMARY
  Medication
  Diet
  Activity level
  Follow-up care
  Wound care
  Phone numbers
  When to call the doctor
  Time of discharge
 
  a. Clinical decision support system
  b. Admission nursing history
  c. Mode of transportation
  d. SOAP notes

[Mochi]

Answer to Question 1

ANS: C
Nursing interventions and treatments (e.g., medication administration) must be documented. Avoid using generalized, empty phrases such as status unchanged or had good day. Do not document retaliatory or critical comments about a patient, like demanding and argumentative. Family is poor is not critical information to chart.

Answer to Question 2

ANS: C
List actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. Clinical decision support systems (CDSSs) are computerized programs used within the health care setting, to aid and support clinical decision making. The knowledge base within a CDSS contains rules and logic statements that link information required for clinical decisions in order to generate tailored recommendations for individual patients that are presented to nurses as alerts, warnings, or other information for consideration. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style.

[Pineapplelove6]

Thanks for the timely response, appreciate it

[daiying98]

Gracias!