The client states: I really don't want anyone to visit me who has ...

[brutforce]

The client states: I really don't want anyone to visit me who has not been cleared by me first. If utilizing SOAP format, this statement would be documented under which category?
 
  1. Subjective data
  2. Objective data
  3. Assessment
  4. Planning

Question 2

A client has specific cultural needs in regard to the plan of care. This information would be found in which of the following?
 
  1. Database
  2. Problem list
  3. Plan of care
  4. Progress notes

[mochi09]

Answer to Question 1

Correct Answer: 1
Rationale 1: Subjective data consist of information obtained from what the client says. When possible, the nurse quotes the client's words; otherwise, they are summarized.
Rationale 2: Objective data consist of information that is measured or observed.
Rationale 3: Assessment is the interpretation or conclusion drawn about the subjective and objective data. This is the area where the problems are documented initially. Then the client's condition and level of progress are subsequently described.
Rationale 4: Planning is the care designed to resolve the problem.

Answer to Question 2

Correct Answer: 2
Rationale 1: The database includes information about the client when admitted to the facility.
Rationale 2: The problem list is derived from the database and is usually kept at the front of the chart. The problem list serves as an index to the numbered entries in the progress notes. All caregivers contribute to the problem list, which includes the client's physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs.
Rationale 3: The plan of care is made with reference to the active problems.
Rationale 4: Progress notes are chart entries made by all health professionals involved in a client's care.

[brutforce]

Both answers were spot on, thank you once again

[mochi09]

Great! Please up vote