Chapter 19: Documenting and Reporting
According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?
Documentation
Besides being an instrument of continuous care, the client's health care record also serves as a(an)?
Legal document
The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates what finding of information?
The physician's assessment and treatment
A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?
progress notes
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:
interpretation of data