QuestionAnswered step-by-stepBasic Nursing ConceptsDocumentation Assignment You are assigned to care

QuestionAnswered step-by-stepBasic Nursing ConceptsDocumentation Assignment You are assigned to care for Raggedy Ann.  Use the following information to write a Focus/DAR note.  Today, at 0900, Raggedy’s indwelling catheter (Foley) was removed.  The MD orders state to perform a bladder scan if patient does not void within 8 hours.  The order also states to do a straight catheterization if bladder scan results are greater than 500 mL.  At 1700, the patient has not voided.  Upon palpation, the bladder is distended and the patient states, “I feel like I have to pee, but I can’t.”   You assist the patient to the toilet.  Patient is unable to void.  The bladder scan reveals 525 ml.  You straight catheterize the patient for 500 mL of clear urine.    Bladder is no longer distended.  Patient encouraged to ambulate to the bathroom and encouraged to increase fluid intake.  Begin documentation at 1700. Date Time Focus                                                                                                     Patient Name:_________________________________________________________________ 1 points for Data section:   all pertinent data charted and correct information in this section1 points for Action section:  all pertinent data charted and correct information in this section1 point for Response section:  all pertinent data charted and correct information in this section1 point-should only be one DAR note (begin documentation at 1700)1 point for date, time, signature done correctly1 point for correct Focus1 point-black pen1 point-error fixed correctly1 point for correct grammar and spelling, correcting errors if needed, black ink, no blanks1 point for patient name on chart 11.  All of the following are poor examples of documentation practices.  Which one places the writer in the most legal jeopardy?A.  The writer squeezes information into a line written hours earlierB.  The writer misspells several words while completing documentationC.  The writer uses blue rather than black inkD.  The writer signs the documentation but omits his or her title 12. One way to expedite the charting process is to:A. ask another nurse to help with some of your charting.B. chart before you perform care.C. chart your care as close to the time of the event as possible.D. chart all your care at the end of the shift.    13.  When assisting a doctor with a procedure, document:A. only what you did.B. why you think the patient is having the procedure done.C. what you think the doctor should have done.D. the doctor’s name and the patient’s response. 14.  Your patient has an oral temperature of 103.2.  You document this finding on the graphic flow sheet.  What other step is necessary?  A. Document this finding on the patient care Kardex.B. Document this finding and your interventions in the progress notes.C. None; you only need to document on the graphic flow sheet.D. Document this finding in the care plan.   15. Match the correct DAR category with each entry.   _____T-99, P-80, R-26, BP 140/90                                       1. D_____Pt states, “I feel so much better.”                              2. A_____Administered Tylenol 1,000 mg. po                       3. R                                                                                                      Revised 9/13/17        Health ScienceScienceNursingShare Question

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