The Human Body in Health and Disease
7th EditionGary A. Thibodeau, Kevin T. Patton
1,505 solutions
The Human Body in Health and Disease
6th EditionGary A. Thibodeau, Kevin T. Patton
1,861 solutions
Exercise Physiology: Theory and Application to Fitness and Performance
11th EditionEdward Howley, John Quindry, Scott Powers
593 solutions
Mecanica de Materiales
9th EditionBarry J. Goodno, James M. Gere
1,185 solutions
Recommended textbook solutions
Clinical Reasoning Cases in Nursing
7th EditionJulie S Snyder, Mariann M Harding
2,512 solutions
Pharmacology and the Nursing Process
7th EditionJulie S Snyder, Linda Lilley, Shelly Collins
388 solutions
Medical Terminology: Learning Through Practice
1st EditionPaula Manuel Bostwick
1,562 solutions
Law and Ethics for Health Professions
9th EditionCarlene Harrison, Karen Judson
836 solutions
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