Are comprehensive charting forms that integrate assessments and nursing actions
Contain only graphic information. such as I&O. vital signs. and medication administration
Are used to record routine aspects of care; they do not contain assessment data
Contain vital data collected upon admission. which can be compared with newly collected data
Complete an occurrence report before leaving.
Do nothing; the next nurse will document it was done.
Write the note of the dressing change into an earlier note.
Make a late entry as an addition to the narrative notes.
It includes organizational reports of unusual occurrences that are not part of the client’s record.
This type of system consists of combined documentation and daily care plans.
It improves interdisciplinary collaboration that improves efficiency in procedures.
This type of system tracks medication administration and usage over 24 hours.
Administering an antibiotic every day
Teaching the importance of handwashing
Assessing a client’s surgical incision
Advising a woman to get an annual mammogram after age 50 years
Established standards of care
Practice supported by scientific research
Activities determined by a scope of practice
Case method nursing
Antibiotics are ineffective in treating viral infections.
When you take a patient’s blood pressure. the patient’s arm should be at heart level.
In Maslow’s framework. physical needs are most basic.
When drawing medication out of a vial. inject air into the vial first.