Answer to Question 1
d
Answer to Question 2
Examples of guidelines for charting include recognizing the significance of charting, including the dietitian's full name and status when signing charts, being timely with charting, never charting for someone else, avoiding documenting procedures until after they have been completed, remembering that medical charts are legal documents and should be treated as such, using only black ink and writing legibly, using clear language while writing and avoiding unfamiliar abbreviations, and avoiding white space. Further, the clinician should document only information that has been observed with objective notes and avoid assumptions.
The tone of the nurse-patient introduction sets the stage for the patient interview and patient care
The patient interview often requires note taking.
Pulmonary function test: spirometry. (a) Normal respiratory volumes, as measured during spirometry.
Nurse palpating the patient's brachial artery
Example of a patient’s ledger in practice management software.
Patient Physical Status Classification