A nurse is using the source record and wants to find the daily weights.Where should the nurse look?
A) Database
B) Medical history and examination
C) Progress notes
D) Graphic sheet and flow sheet

Question

Quizplus · Accepted Answer

In a source record,the patient's chart has a separate section for each discipline (e.g.,nursing,medicine,social work,respiratory therapy)in which to record data.Graphic sheets and flow sheets are records of repeated observations and measurements such as vital signs,daily weights,and intake and output.In the problem-oriented medical record,the database section contains all available assessment information pertaining to the patient (e.g.,history and physical examination,the nurse's admission history and ongoing assessment,the dietitian's assessment,laboratory reports,radiologic test results).In the source record,the medical history and examination contain results of the initial examination performed by the physician,including findings,family history,confirmed diagnoses,and medical plan of care.In the source record,the progress notes contain an ongoing record of the patient's progress and response to medical therapy and a review of the disease process; it often is interdisciplinary and includes documentation from health-related disciplines (e.g.,health care providers,physical therapy,social work).

A Nurse Is Using the Source Record and Wants to Find