Author Question: A cardiac specialty hospital has several written plans in place for clients who are admitted, ... (Read 16 times)

serike · **on:** Jul 23, 2018

A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions.

Typical nursing diagnoses as well as standard nursing interventions are included in these plans. Which type of form is this hospital utilizing?
1. Standardized care plans
2. Traditional care plans
3. Critical pathways
4. Kardex

Question 2

The nurse is documenting client care on flow sheets that identify abnormal assessment findings. Which type of documentation system is the nurse using?

1. Computerized documentation
2. Focus charting
3. SOAP charting
4. Charting by exception

Jevvish · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 1
Rationale 1: Standardized care plans were developed to save documentation time. These plans may be based on an institution's standards of practice, thereby helping to provide a high quality of nursing care. Standardized care plans are usually individualized to address each client's specific needs.
Rationale 2: Traditional care plans are written for each client, are specific, and are individualized for that client.
Rationale 3: Critical pathways are used in case management, involving a multidisciplinary approach to planning and documenting client care.
Rationale 4: The Kardex is a concise method of organizing and recording data about a client, making information quickly accessible for all health professionals.

Answer to Question 2

Correct Answer: 4
Rationale 1: Computerized documentation is a way to manage the volume of information required in a client's chart, and different systems may include a variety of setups and programs.
Rationale 2: Focus charting is organized into data, action, and response sections, referred to as DAR.
Rationale 3: SOAP charting is a way to organize data and information in the client's record: S = subjective data; O = objective data; A = assessment; P = plan.
Rationale 4: Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE.