Which documentation tool will the nurse use to record the clients vital signs every 4 hours quizlet?

CHARTING BY EXCEPTION

Charting by exception (CBE) is a shorthand
documentation method that makes use of
well-defined standards of practice; only
significant findings or "exceptions" to these
standards are documented in CBE narrative-
style notes. The question is asking about a
pregnant woman with hypertension. This is not
an expected situation for a typical pregnant
woman, so CBE is a way to document this situation so that it will be immediately seen in the documentation.

The PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). This would not be the best method of documentation if the nurse wanted the documentation to stand out regarding the client's condition.

Narrative notes address routine care, normal findings (findings that do not call for changes in the plan of care), and client problems identified in the plan of care.

SOAP notes (Subjective data, Objective data, Assessment, Plan) is used to organize entries in the progress notes, focusing primarily on the client and any identified problems.

Which principle should guide the nurse's documentation of entries on the client's health care record quizlet?

Which is the proper way to document midnight in a clients record?

What dual purpose does an audit serve quizlet?

Which statement is not true regarding a medication administration record Mar?