Fundamentals of Nursing Q 27
The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets:
A. Are comprehensive charting forms that integrate assessments and nursing actions.
B. Contain only graphic information, such as I&O, vital signs, and medication administration.
C. Are used to record routine aspects of care; they do not contain assessment data.
D. Contain vital data collected upon admission, which can be compared with newly collected data.
Correct Answer: A. Are comprehensive charting forms that integrate assessments and nursing actions
Nursing assessment flow sheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. A flow sheet is simply a one- or two-page form that gathers all the important data regarding a patient’s condition. The flow sheet is housed in the patient’s chart and serves as a reminder of care and a record of whether care expectations have been met.
Option B: Graphic information, such as vital signs, I&O, and routine care, may be found on the graphic record. This where records of serial measurements and observations, nursing interventions, and nursing care plans are recorded.
Option C: Nursing documentation covers a wide variety of issues, topics, and systems. Researchers, practitioners, and hospital administrators view recordkeeping as an important element leading to continuity of care, safety, quality care, and compliance.
Option D: The admission form contains baseline information. In health care organizations, the EHR, oral reports, handoffs, conferences, and health information technologies (HIT) are intended to facilitate information flow. In particular, the JCAHO specifically conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care.