Which information would the nurse document in a patients medical record Quizlet

Q: Which information would the nurse document in a patients medical record?

The patients name, age, and admitting diagnosis. Allergies to food and medications. That the patients pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of acetaminophen. The nurse is preparing a patient for discharge.

Inhaltsverzeichnis Show

Which information would the nurse document in a patient's medical record?
What information should be included in a patient's medical records quizlet?
Which data would the nurse include in the documentation of patient care?
What type of information does a medical record contains?

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2, 4, 5

Good quality documentation should be factual, accurate, current, complete, and organized. Using the word seems indicates that the nurse is not communicating a fact but rather, stating her opinion. "Sounds are produced" are terms that indicate the nurse lacks knowledge. It should be written as "wheezing is present while exhaling." By documenting "copious amounts," the nurse is not providing a detailed enough description of the amount, color, and consistency of the sputum. The statement about the vital signs has all the required information accurately documented. Recording the presence of rhonchi in the lower bases of the lungs on auscultation is also a correct statement.

1, 2, 3, 4

After confirming the patient's name, room number, and diagnosis, the nurse should always document when he or she administers a medication. Administering the morphine without documenting it would be inappropriate. When orders are given by telephone, the nurse carefully notes the prescription and reads it back to the primary healthcare provider for verification. In the report, the nurse indicates whether it is a telephone order (TO) or verbal order (VO) and mentions the name of the patient, complete ordering information, name of the primary healthcare provider, and date and time of the TO or VO; the nurse also documents the order was read back to provider. This is signed by the ordering primary healthcare provider within a set time frame. The nurse does not just write that the medications were administered "as per orders." The telephone orders are discretely and carefully documented with specific information such as the date, time, patient, and the primary healthcare provider's name. Vague documentation and informatics can lead to misinterpretation and legal claims.

The nurse is caring for a patient who has been diagnosed with pneumonia. The nurse is reviewing the assessment details of the patient: "Blood pressure is 150/90 mm Hg; pulse is 92 beats/minute, and the respiratory rate is 22 breaths/minute. The patient seems to have difficulty breathing. Sounds are produced when the patient exhales. Auscultation reveals rhonchi in the lower lung bases. Copious amounts of phlegm have been produced since morning." A senior nurse finds this to be poor quality of documentation. Which statements in the documentation are considered to be poor quality documentation and informatics? Select all that apply.

A)Vital signs: blood pressure 150/90 mm Hg, pulse rate 92 beats/minute, and respirations 22 breaths/minute.

B)The patient seems to have difficulty breathing.

C)Auscultation reveals rhonchi in the lower lung bases.

D)Sounds are produced when exhaling.

E)Copious amounts of sputum produced since morning

Which information would the nurse document in a patient's medical record?

The patient's name, age, and admitting diagnosis. Allergies to food and medications. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of acetaminophen. The nurse is preparing a patient for discharge.

What information should be included in a patient's medical records quizlet?

Information on a patient such as, demographics, progress notes, problems, medication, vital signs, past medical history, immunizations, laboratory data, radiology pictures, and other personal data (height, weight, and billing information). Information that is provided by the patient and then updated as necessary.

Which data would the nurse include in the documentation of patient care?

The nursing record should include assessment, planning, implementation, and evaluation of care. Ensure the record begins with an identification sheet. This contains the patient's personal data: name, age, address, next of kin, carer, and so on.

What type of information does a medical record contains?

Medical records are the document that explains all detail about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication. If written correctly, notes will support the doctor about the correctness of treatment.