Asked by Nikki Haynes on Apr 27, 2024
Verified
The nursing assistant tells the RN that when the patient's vital signs were taken,the patient complained that she was in a lot of pain.The nursing assistant then tells the nurse that she charted the patient's complaint when she charted the vital signs.What instruction does the nurse need to provide to the nursing assistant?
A) The nursing assistant needs to make sure she uses the SBAR format when entering notes.
B) Nursing assistants are not allowed to chart vital signs.
C) Only the nurse can write in the progress notes.
D) The nursing assistant needs to write using blue ink to distinguish from the RN note.
SBAR
SBAR stands for Situation, Background, Assessment, and Recommendation, a structured method of communication used in healthcare to facilitate clear and concise information exchange.
Progress Notes
Documentation of a patient's clinical status during a hospital stay or over the course of outpatient care.
Chart Vital Signs
The act of recording key measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate.
- Understand the importance and types of documentation in nursing and healthcare.
- Differentiate between various documentation formats and their appropriate use.
Verified Answer
Learning Objectives
- Understand the importance and types of documentation in nursing and healthcare.
- Differentiate between various documentation formats and their appropriate use.
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