Quiz 15: Documenting and Reporting
The quality of the client care is dependent on effective documentation and communication of the client's details. The client's physiological and mental details are documented or recorded digitally and manually. This procedure should be very sensitive, detailed, accurate and confidential to ensure legal qualification. According to the case presented, Mr. Anderson, an 80-years-old male, has been presented with acute pain. He has a health history of hypertension and reports of fatigue and lethargy associated with the continuous pain. Following are the guidelines for documenting that were not followed in the presented documentation: 1. Date and time: The date of documenting the assessment of the patient has not been mentioned. Only the time of each recording has been provided. 2. Inappropriate timing: The documentation should have been more frequent as the client has a rapidly fluctuating blood pressure. 3. A certain change in a physiological condition should be recorded as soon as the nursing intervention has been implemented, which is absent or uncertain in the documentation presented. 4. The documentation should contain a chart showing the physiological changes and the corresponding follow-up actions that have been taken. 5. The comments of the client should be quoted word by word, not to be narrated in the documentation. 6. The nurse should not use words such as 'complainer' and 'disagreeable' in the documentation because these words reflect prejudice. 7. "Client fell out of bed" is a vague and non-specific record. The record should contain specific, objective and factual information. 8. The documentation lacks the client's response to the nursing interventions.
The quality of the client care is dependent on effective documentation and communication of the client's details. The client's physiological and mental details are documented or recorded digitally and manually. This procedure should be very sensitive, detailed, accurate, and confidential to ensure legal qualification. Leaving the file of the client accessible on the computer endangers the client's confidentiality. This action does not ensure client confidentiality. Sharing the computer password with others increases the risk of assessment of the file without authorization. This endangers the client's confidentiality. Leaving the client's computer at the computer worksheet at the computer workstation endangers the client's confidentiality because it might be accessible to other persons. Hence, the options1, 2 and 4 are incorrect. The nurse should always log off from the client's file after accessing it in the computer. This action of the nurse ensures the confidentiality of the computer record of his/her client. Hence, the correct answer is option .
According to the given case study, Mr. Anderson, an 80-years-old male, has been presented with acute pain. He has a health history of hypertension and reports of fatigue and lethargy associated with the continuous pain. Hypertension is described as the long-term medical condition, which does not cause the symptoms. Persisting elevation in the pressure of blood in arteries is known as the high blood pressure (HBP). Various lifestyle factors responsible for increasing the blood pressure includes the consumption of alcohol, smoking, excess salt consumption and excess body weight. Following aspects should be documented by the nurse for the nursing diagnosis of acute pain: 1. The location of the pain: The pain is reported to be in the back. But the nurse should confirmedly pinpoint the exact location of the pain. 2. The nature of the pain: The nurse should determine and document the nature of the pain as to whether it is throbbing, radiating, crushing or shooting. 3. The client's response to pain medication should be documented.