DOCUMENTATION AND REPORTING NCLEX

A major advantage of problem-oriented medical records (POMRs) is that they: A. Encourage collaboration B. Are highly efficient C. Don't require frequent updating of the problem list D. Are easily understood by all caregivers

A. Rationale: A major advantage of problem-oriented medical records (POMRs) is that they encourage collaboration. POMRs are somewhat inefficient, and are difficult to use to retrieve information. The problem list must be revised and updated frequently in order to implement appropriate care for the client. Caregivers differ in their ability to use POMRs.

Which of the following forms is not used to document nursing activities? A. Laboratory reports B. Critical pathways C. Kardex D. Assessment forms

A. Rationale: Laboratory reports are not used in documenting nursing activities. Critical pathways, Kardex, and assessment forms document nursing activities.

The nurse works at an organization that is installing a new computerized record system. What should the nurse learn that has been implemented to help ensure the security of the client?(select all that apply) A. A firewall to protect the server from unauthorized access B. One unit password to protect the units information C. Expectation to log off a terminal after using it D. Expectation to turn the monitor away from view when unattended E. Requirement to shred all computer-generated worksheets

A. A firewall to protect the server from unauthorized access C. Expectation to log off a terminal after using it E. Requirement to shred all computer-generate worksheets

The nurse is teaching medication administration to a client being discharged. Which instruction should the nurse rewrite for this client? A. Lasix, 20mg, po bid B. Lasix, 20 mg tablet, twice daily C. Lasix, 20 mg by mouth two times a day D. Lasix 20 mg by mouth 8 am and 2 pm

A. Lasix, 20mg, po bid

A client in a long term care is scheduled for a review of the assessment and care screening process. Where should the nurse document this information? A. Minimum data system (MDS) B. Omnibus Budget reconciliation act C. Charting by exception D. Kardex

A. Minimum data systems

When attempting to locate recent lab results, the new nurse employee notices that each department has a separate section in the clients chart. Which type of documentation system is the nurse using? A. Source- oriented record B. Problem- oriented record C. Case management D. Focus Charting

A. Source- oriented record

A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. Which type of form is this hospital utilizing? A. Standardized care plans B. Traditional care plans C. Critical pathways D. Kardex

A. Standardized care plans

The client states: I really don't want anyone to visit me who has not been cleared by me first. If utilizing SOAP format, in which category should the nurse document this statement? A. Subjective data B. Objective data C. Assessment D. Planning

A. Subjective data

A hospital is not able to reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. Which problem with documentation might have caused the lack of reimbursement? A. The clients record contained an incorrect diagnosis related group (DRG) B. The client was charged for an ECG C. A code cart was opened and the client was charged for medications opened but not used D. The physician made a diagnostic mistake

A. The clients record contained an incorrect diagnosis related group (DRG)

A client is admitted to a long-term care facility. The nurse knows that federal law requires the use of 1)The Minimum Data Set (MDS) for assessment 2)Situation-background-assessment-recommendation (SBAR) for reporting 3)Healthcare Financing Administration guidelines prior to surgery 4)Joint Commission guidelines for discharge planning

ANS: 1

The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? CBE 1)Reduces the time nurses spend charting 2)Addresses the patient's concerns holistically 3)Establishes an ongoing care plan from admission 4)Is most useful when constructing a timeline of events

ANS: 1

The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? CBE: 1) reduces the time nurses spend charting. 2) addresses the patient's concerns holistically. 3) establishes an ongoing care plan from admission.

ANS: 1

The nurse administers a scheduled dose of heparin 5,000 units subcutaneously at 2100 and documents in the medication administration record that the dose was administered. What other information is important for the nurse document on the MAR? 1) Injection site 2) Previous site of administration 3) Patient response to medication 4) Heart rate prior to administration

ANS: 1

The nurse administers heparin 5000 units subcutaneously at 2100 and documents in the medication administration record that the dose was administered. What other information is important for the nurse document? 1)Injection site 2)Previous site of administration 3)Patient response to medication 4)Heart rate prior to administration

ANS: 1

The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting: 1) separates the health record according to discipline. 2) organizes documentation around the patient's problems. 3) highlights the patient's concerns, problems, and strengths. 4) is designed to streamline documentation.

ANS: 1

The nurse is working on a unit that uses nursing assessment flowsheets. Which statement best describes this form of charting? Nursing assessment flowsheets: 1) are comprehensive charting forms that integrate assessments and nursing actions. 2) contain only graphic information, such as I&O, vital signs, and medication administration. 3) are used to record routine aspects of care, but do not contain assessment data. 4) contain vital data collected upon admission, which can be compared with newly collected data.

ANS: 1

The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? 1)Repeat the order to the prescriber even if she believes she understood the order correctly. 2)Immediately notify the pharmacy of the order and verify it with a pharmacist. 3)Ask the unit secretary to listen to the prescriber on the phone to verify the order. 4)Transcribe the order onto note paper and verify the dosage in a drug handbook.

ANS: 1

The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports? 1)"Occurrence reports track problems and identify areas for quality improvement." 2)"Occurrence reports are required by the Food and Drug Administration to report drug errors." 3)"The Joint Commission requires occurrence reports for all client falls." 4)"Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence."

ANS: 1

The patient's medical record contains the following documentation: 06/05/05 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 via18 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? 1)Narrative 2)Focus 3)SOAP 4)PIE

ANS: 1

The patient's medical record contains the following documentation: 06/05/15 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 via18 gauge intravenous 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? 1) Narrative 2) Focus 3) SOAP 4) PIE

ANS: 1

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident of a long-term care facility? 1)14 days 2)3 days 3)2 days 4)24 hours

ANS: 1

Which action by the nurse breaches patient confidentiality? Select all that apply. 1)Leaving patient data displayed on a computer screen where others may view it 2)Remaining logged on to the computer system after documenting patient care 3)Faxing a patient report to the nurses' station where the patient is being transferred 4) Informing the nurse manager of a change in the patient's condition

ANS: 1, 2

In performing a hand-off report, the nurse should communicate information on which of the following? Select all that apply. 1)Teaching performed 2)Any change in client status 3)Treatments administered 4)Hygiene measures performed

ANS: 1, 2, 3

The nurse who understands the electronic health record (EHR) can do which of the following? Select all that apply. 1)Facilitate evidence-based nursing practice 2)Promote efficient use of the nurse's documentation time 3)Reduce the opportunity for interdisciplinary collaboration 4)Ensure improved client safety and outcomes

ANS: 1, 2, 4

Which statement by the student nurse indicates an understanding of the nursing Kardex®? Choose all correct answers. 1)"The Kardex® pulls data from multiple areas of the patient's chart." 2)"The Kardex® is usually kept at the patient's bedside." 3)"The Kardex® is used to document patient response to interventions." 4)"The Kardex® summarizes the plan of care and guides nursing care."

ANS: 1, 4

A patient refuses a dose of medication. How should the nurse document the event? 1)Patient is uncooperative and refuses the prescribed dose of digoxin. 2)Patient refuses the 0900 dose of digoxin. 3)Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. 4)0900 dose of digoxin not given.

ANS: 2

A resident in a long-term care facility receiving Medicare funds requires care for a stage 2 pressure ulcer. How often must the nurse document this patient's care? 1)Every 2 weeks 2)Every shift 3)Every week 4)Every 3 months

ANS: 2

The nurse documents the following: "Patient able to administer own insulin per subcutaneous injection using correct technique." In Focus Charting, this statement would be followed by which letter? 1) D 2) R 3) P 4) E

ANS: 2

The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone order for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order? 1)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain. Kay Andrews, RN 2)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN 3)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain V.O.: Dr. D. Kelly/Kay Andrews, RN 4)09/02/13 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN

ANS: 2

The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall. 1)Patient found on floor in pain after falling out of bed. 2)Patient found on floor after falling out of bed; found by NAP Smith. 3)Patient fell out of bed but is currently in bed. 4)Patient reminded to not climb OOB after falling.

ANS: 2

The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeon's order? The nurse 1)Performs oral care 2)Assists the patient out of bed 3)Assists the patient with bathing 4)Changes the patient's operative dressings

ANS: 2

What is the purpose of completing an occurrence report? 1)Provide a legal defense should the patient seek legal action after an unusual occurrence 2)Track problems and identify areas for quality improvement 3)Report errors to the Food and Drug Administration 4)Report medical errors to the Joint Commission

ANS: 2

Which of the following incidents requires the nurse to complete an occurrence report? 1) Medication given 15 minutes after scheduled dose time 2) Patient's dentures lost after transfer 3) Worn electrical cord discovered on an IV infusion pump 4) Prescription without the route of administration

ANS: 2

A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1 hour PRN pain. When should the nurse administer the medication? 1)Every hour around-the-clock 2)Immediately after taking off the order 3)As needed, but not more than once per hour 4)1 hour after the last administered dose

ANS: 3

A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1 hour prn pain. When should the nurse administer the medication? 1) Every hour around the clock 2) Immediately after taking off the order 3) As needed, but not more than once per hour 4) 1 hour after the last administered dose

ANS: 3

A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system? 1)It involves a cooperative effort among various disciplines. 2)The system requires diligence in maintaining a current problem list. 3)Data may be fragmented and scattered throughout the chart. 4)It allows the nurse to provide information in an unorganized manner

ANS: 3

A patient is admitted to the emergency department with a stroke. After being stabilized, the patient's needs are best met if the nurse documents a care plan that provides for 1)Acute interventions 2)Patient teaching 3)Discharge needs 4)Family health data

ANS: 3

A patient is admitted to the emergency department with a stroke. After being stabilized, the patient's needs are best met if the nurse documents a care plan that provides for: 1) acute interventions. 2) patient teaching. 3) discharge needs. 4) family health data.

ANS: 3

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement? 1)Hypertension 2)Rheumatoid arthritis 3)Postoperative colon resection 4)Follow all three plans

ANS: 3

At 1000 on 11/14/10, the nurse takes a telephone order for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order? 1)11/14/13 at 1200 2)11/14/13 at 2200 3)11/15/13 at 1000 4)11/16/13 at 1000

ANS: 3

The client asks the nurse why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system? 1) It includes organizational reports of unusual occurrences that are not part of the client's record. 2) This type of system consists of combined documentation and daily care plans. 3) It improves interdisciplinary collaboration that improves efficiency in procedures. 4) This type of system tracks medication administration and usage over 24 hours.

ANS: 3

The nurse makes a mistake while documenting in the patient's health record. Which action should the nurse take? 1) Use an opaque white fluid to cover the documentation error. 2) Completely cover the documentation error with black ink. 3) Draw a line through the error and initial the change. 4) Use correction tape to make the documentation correct.

ANS: 3

The nurse makes a mistake while documenting in the patient's health record. Which action should the nurse take? 1)Use an opaque white fluid to cover the documentation error. 2)Completely cover the documentation error with black ink. 3)Draw a line through the error and initial the change. 4)Use correction tape to make the documentation correct.

ANS: 3

The patient's health record contains the following provider's order: furosemide (Lasix) 40 mg intravenously STAT. If the nurse later needed to know when the medication had been given and the patient's response to the medication, where would he look? 1) Progress notes 2) Graphic record 3) Narrative notes 4) MAR

ANS: 3

The patient's health record contains the following provider's order: furosemide 40 mg intravenously STAT. If the nurse later needed to know when the medication had been given and the patient's response to the medication, where would he look? 1)Progress notes 2)Graphic record 3)Narrative notes 4)MAR

ANS: 3

When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? 1) NA 2) NDA 3) NKA 4) NPO

ANS: 3

Which set of topics makes up a hand-off report given in a recommended format? 1)Data-action-response 2)Subjective-objective-assessment-plan 3)Situation-background-assessment-recommendation 4)Patient-diagnosis-medications-activity

ANS: 3

which of the following is a disadvantage of paper health records? 1)Assist collaboration 2)Provide cautionary reminders 3)Are sometimes illegible 4)Serve as a resource

ANS: 3

A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client's condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first? 1)Study the discharge plan. 2)Check the graphic data for vital signs. 3)Examine the history and physical. 4)Look for an advance directive.

ANS: 4

At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? 1) Complete an occurrence report before leaving. 2) Do nothing; the next nurse will document it was done. 3) Write the note of the dressing change into an earlier note. 4) Make a late entry as an addition to the narrative notes.

ANS: 4

The nurse has just medicated a client for pain. Documentation of this intervention would be found on the: 1) Kardex® and graphic sheet 2) IPOC and discharge summary 3) Flow sheet and the assessment checklist 4) Progress notes and the MAR

ANS: 4

Documentation of nursing care for home health patients requires ongoing assessment of need for skilled nursing care. 1) True 2) False

ANS: A

Which statement by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply. 1)"I can wait until the end of the shift to document my care." 2)"Charting every 2 hours is the most appropriate way to document nursing care." 3)"I find it easier to chart before I go to lunch and then after my shift report." 4)"I should chart as soon as possible after nursing care is given."

ANS:1 ,2, 3

Who is legally entitled to view a client's medical records without written consent? A. Close friends of the client B. Health care professionals who are caring for the client C. Insurance company D. Client's son

B Rationale: Health care professionals who are caring for a client are legally entitled to client records. Friends should not have access to the client's records. Insurance company would only be granted access after the client has signed a formal consent. The client's son cannot access the records without signed consent.

A client is admitted to the hospital with diabetes, a wound infection, and senile dementia. Would a case management model using critical pathways be appropriate for this client? A. Only if critical pathways are ordered by the physician B. No, because clients with multiple diagnoses are difficult to document on a critical pathway C. The use of critical pathways depends on the client's payer source. D. Yes, because multiple diagnoses are easy to track on a critical pathway

B. Rationale: A case management model would not be used, because clients with multiple diagnoses are difficult to document on a critical pathway. A physician's order is not required for case management. The client's payer source does not dictate the use of case management. Multiple diagnoses are difficult to track on a critical pathway.

Discharge and referral summaries usually include all of the following except: A. Descriptions of the client's physical and mental status at discharge B. Laboratory and diagnostic studies C. Unresolved, continuing problems D. Current medications

B. Rationale: Laboratory and diagnostic studies generally are not included in discharge summaries. Documentation of the client's outcome must be included in the final record. Unresolved problems must be listed so that they can be addressed and corrected, either in another institution or on an outpatient basis. Current medications must be listed in order to ensure continuity of care and appropriate follow-up.

Which of the following statements best describes the PIE charting model? A. PIE does not require a nurse to review all nursing notes before giving care. B. PIE incorporates the care plan into the client's progress notes. C. PIE uses the terms subjective data, objective data, assessment, and planning. D. PIE is a necessary supplement to the client's care plan.

B. Rationale: PIE incorporates the care plan into the client's progress notes. The PIE charting model does require a review of all nursing notes. PIE uses the terms subjective data, objective data, assessment, planning and describes the components of the SOAP acronym. The SOAP charting model is a supplement to the client's care plan.

A client did not meet the goal of walking unassisted, with out assistive devices, by discharge from rehabilitation. The case manager using a critical pathway should identify this outcome as being which of the following? A. unattainable goal B. A variance C. An error in care planning D. An error in intervention implementation

B. A variance

A client who is bring transferred to a rehabilitation center asks the nurse if he can take his chart with him, as its his record. How should the nurse respond to this clients requests? A. You'll has to ask your doctor for permission to do that B. Actually, the original record is property of the hospital, but you are welcome to copies of your record C. We'll make sure that all of your records are sent ahead to the rehab hospital, so you don't really have to worry about those details D. There's a new law that protects your records, so you're not going to be able to have access to them

B. Actually, the original record is property of the hospital, but you are welcome to copies of your record

The nurse is conducting a survey of personnel to see what the general feeling is before implementing computerized charting in an acute care hospital. What should the nurse select as positive aspects of implementing this type of system? (select all that apply) A. The system is relatively inexpensive to maintain B. Bedside terminals eliminate worksheets and note taking C. The system links to various sources of client information D. The system better protects client privacy E. Information is legible F. Results, requests, and client information can be sent and received quickly

B. Bedside terminals eliminate worksheets and note taking C. The system links to various sources of client information E. Information is legible F. Results, requests, and client information can be sent and received quickly

The nurse administered analgesic medications to an assigned client via central line. In which section of the PIE charting should the nurse document this information? A. Plan B. Intervention C. Evaluation D. Progress notes

B. Intervention

A client has specific cultural needs that affect the plan of care. In which part of the clients problem-oriented medical record should the nurse document this information? A. Database B. Problem list C. Plan of care D. Progress notes

B.Problem list

Which of the following statements best describes a source-oriented record? A. A problem list is maintained at the front of the chart. B. Source-oriented charting is the newest type of medical record. C. Each department uses a separate part of the client's chart. D. Information is arranged according to the client's problems.

C. Rationale: A source-oriented record is generally considered best when each department uses a separate part of the client's chart. A problem list describes a problem-oriented record. Source-oriented charting is a traditional method. Information is arranged according to problems in a problem-oriented medical record.

The nurse makes chronological entries in a clients chart that include documentation about routine care provided, assessment findings, and client problems during a 12 hour shift. Which type of charting is this nurse completing? A. Problem- oriented recording B. Source- oriented recording C. Narrative charting D. Plan of care

C. Narrative Charting

The nurse is reviewing a clients chart in a facility that utilizes problem-oriented recording. In which section would the nurse find the most recent physician orders? A. Database B. Problem list C. Plan of care D. Progress notes

C. Plan of care

When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding? A. Client fell out of bed, but did not push the call button for assistance B. Client became tangled in the bed linens, then called for assistance after falling out of bed C. Recorder responded to clients call light, upon entering the room, found client on floor D. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens

C. Recorder responded to clients call light, upon entering the room, found client on floor

After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why its permissible for them to review and have access to client records in the clinical area. How should the nursing instructor respond? A. Confidentiality and privacy laws don't apply to students B. Most students review so many records and charts that they could not possibly remember details from any one of them C. Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence. D. As long as the clinical instructor is in the area, accessing client records is part of the education process

C. Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence

The nurse working in a hospital that utilizes a charting by exception documentation system notes that a client did not require care in all of the areas identified on a flow sheet. Which action should the nurse take? A. Leave blank areas B. Leave the areas blank, but then add an extensive explanation in the progress notes section of the chart C. Write N/A on the flow sheet in the areas that are not applicable to the client D. Make sure this information gets passed along in the shift report.

C. Write N/A on the flow sheet in the areas that are not applicable to the client

Which of the following nursing notations is an example of subjective data? A. Right hand is cool to touch. B. Unable to grasp objects with right hand C. Gait is unsteady. D. Complains of right-sided weakness.

D. Rationale: Complains of right-sided weakness is an example of subjective data. Right hand is cool to touch is an objective, measurable finding. Unable to grasp objects with right hand is an objective statement. Gait is unsteady is an objective, measurable finding.

Which of the following actions by a nurse would endanger the confidentiality of a client's records? A. The nurse closes a client's computer file and logs off. B. Refusing to share a computer password. C. The nurse assures a client diagnosed with AIDS that only the health care team will know the diagnosis. D. The nurse logs on to the client's file and leaves the computer to answer the client's call light.

D. Rationale: Logging on to the client's file and leaving the computer to answer the client's call light would allow unauthorized individuals to access the client's records. Closing a file and logging off would protect confidentiality. Refusing to share a computer password would protect confidentiality. Assuring a client diagnosed with AIDS that only the health care team will know the diagnosis would not endanger confidentiality.

How often should a plan of care be revised for long-term care clients? A. Whenever a new physician's order is written B. When medications are changed C. Each week, regardless of the client's health status D. Every three months, or whenever the client's health status changes

D. Rationale: The plan of care should be revised every three months, or whenever the client's health status changes. The care plan does not need to be revised each time a new physician's order is written. The care plan does not need to be revised when medications are changed, unless there is a corresponding change in the client's status. The care plan does not require revision every week unless the client's health status has changed.

The nurse is documenting client care on flow sheets that identify abnormal findings. Which type of documentation system is the nurse using? A. Computer documentation B. Focus charting C. SOAP charting D. Charting by exception

D. Charting by exception

After completing the client care and documenting it in the progress notes, the nurse realizes that documentation was placed on the wrong medical record. What should the nurse do? A. Use white out over the mistake B. Take a wide permanent marker and blacken out all the documentation C. Put an X through the entire page, identify it as an error, initial, and move on to the correct chart D. Draw a single line through the documentation, write mistaken entry next to the original entry, and initial it

D. Draw a single line through the documentation, write mistaken next to the original entry, and initial it

Before providing care, the nurse reviews the clients pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information. Which form should the nurse review to learn all of this information? A. The clients medical records B. The MAR (medication administration record) C. The written care plan D. The kardex

D. The kardex