Asked by Christian Cooper on Jun 03, 2024
Verified
The patient's medical record contains the following documentation: 06/05/17 0200 Received patient from the E.D.BP 80/52,HR 118,RR 24,temp 104°F.Arouses to verbal stimuli but drifts off to sleep.Normal saline infusing in left arm via 18-gauge IV catheter at 250 mL/hr.Urinary catheter draining scant dark amber urine.Pt receiving O2 at 6 L/min via nasal cannula.Lungs with coarse crackles at the left base.Loose cough present.Pt unable to expectorate secretions.-Ann Davids,RN
Which type of charting has the nurse used?
A) Narrative
B) Focus
C) SOAP
D) PIE
Narrative
A spoken or written account of connected events; a story that may be factual or fictional, used for entertainment, education, or recording history.
Medical Record
A comprehensive document containing a patient's personal health history, including diagnoses, treatments, tests, and outcomes.
- Acknowledge the importance of exact documentation within patient care, including the administration of medicines and the documentation of patient outcomes.
Verified Answer
EM
Ezekiel MachebeleJun 05, 2024
Final Answer :
A
Explanation :
The nurse has used Narrative charting. This type of charting involves the use of a descriptive narrative to record patient information and care provided. It provides a chronological order of events and captures relevant patient information in a detailed and comprehensive manner.
Learning Objectives
- Acknowledge the importance of exact documentation within patient care, including the administration of medicines and the documentation of patient outcomes.
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