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A measurable patient goal b progress toward goal c

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a.Measurable patient goalb.Progress toward goalc.Need for referrald.Discharge dateANS: A, BThe information within a recorded entry must be complete, containing appropriate andessential information. There are criteria for thorough communication for certain healthsituations. For example, when recording discharge planning, measurable patient goals orexpected outcomes, progress toward goals, and need for referrals are always included.DIF:Cognitive Level: UnderstandingOBJ: NCLEX: Safe and Effective Care EnvironmentTOP: Integrated Process: Communication and Documentation4.In a POMR charting method of documentation, which of the following items are used?(Select all that apply.)a.Progress notesb.Databasec.Medical diagnosisd.Problem liste.Care planANS: A, B, D, EThe problem-oriented medical record (POMR) is a structured method of documentation thatemphasizes a patient’s problems. It is organized using the nursing process. Organization ofdata is by problem or diagnosis. Ideally each member of the health care team contributes to asingle list of identified patient problems. Each recording includes a database, problem list,care plan, and progress notes.N
DIF:Cognitive Level: RememberingOBJ: NCLEX: Safe and Effective Care EnvironmentTOP: Integrated Process: Communication and Documentation
Chapter 04: Patient Safety and Quality ImprovementPerry et al.: Nursing Interventions & Clinical Skills, 7th EditionMULTIPLE CHOICE1.The nurse is caring for an older patient who has a non–weight-bearing cast on the left lowerextremity. The patient ambulates without using a walker despite repeated instruction from thenurse to call for assistance. Which response by the nurse is most likely to keep the patientfrom falling?

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Term
Fall
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Tags
Nursing, Health care provider, Nursing Educator

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