Question

Select all that apply: When documenting the occurrence in the medical record, Rachel will include the following: A. A description of what happened B. Th e fi ndings from her focused assessment C. What actions were taken D. Th at an incident report was completed

Short answer

The correct options are A, B, and C. Options A, B, and C are the ones generally included in a medical record documentation. However, whether an incident report was completed (Option D) is not typically included in the medical record.

Step-by-step solution

Analyzing Option A

Option A suggests including a description of what happened. In any medical event documentation, it is important to have a detailed account of the event, which makes this option a probable selection.

Analyzing Option B

Option B suggests including the findings from her focused assessment. This is another essential part of medical documentation. Rachel needs to document her findings upon assessing the situation or the patient. Therefore, this option is correct.

Analyzing Option C

Option C proposes including the actions that were taken. It is not only important to document what happened and what assessments were made, but also what actions were undertaken in response to which. This ensures accountability and can be helpful for future reference or for any further treatment. Therefore, this option is correct.

Analyzing Option D

Option D advises to include that an incident report was completed. Though completing an incident report itself is important, including this information in the medical record is not part of the standard medical record documentation. Incident reports are separate documents used for internal risk management. Therefore, this option is incorrect.

Key concepts

Medical Event Documentation

Proper medical event documentation is pivotal in the healthcare setting as it contributes to the continuity of care and legal protection. It includes a clear, objective, and factual description of what occurred during a medical event. For any healthcare professional, understanding how to accurately document a medical event is crucial.

When documenting, the details must be precise and written in a chronological order. It's essential to avoid ambiguous language and to record the time, date, and specific observations made during the event. For example, rather than stating 'patient fell', a more detailed account would be 'patient slipped on wet floor, landing on right side at approximately 10:35 am'.

Another aspect of thorough medical event documentation involves recording the context of the event, patient statements, and any witnesses. This information provides a comprehensive picture of the circumstances surrounding the incident which is vital for subsequent treatment plans and for legal considerations should there be any investigations.

Focused Assessment Reporting

Focused assessment reporting is part of the systematic approach that nurses use to identify a patient's specific health issues. It involves performing and documenting an assessment that is concentrated on a particular concern or system, particularly when a patient exhibits new symptoms or a change in condition.

Nurses use their clinical judgement to decide which areas require immediate attention, thereby carrying out assessments that are more targeted. The findings from this assessment should be systematically recorded to inform colleagues and other healthcare providers of the patient's current health status. An effective focused assessment report would include vital signs, patient expressions of discomfort, the appearance of the affected area, or other relevant phenomena.

Furthermore, it’s necessary to prioritize and select relevant data, avoiding any superfluous information that doesn't pertain to the acute issue. This concise approach aids in efficiently conveying critical information that is necessary for directing immediate patient care and potential interventions.

Nursing Actions Documentation

Documenting nursing actions is a fundamental aspect of the nursing process and ensures that all interventions and care provided to the patient are recorded. It is a legal and professional responsibility for nurses to thoroughly document the care they deliver.

Each nursing action taken, ranging from medication administration to patient education, should be documented with precision. This includes the time the action was performed, the rationale behind it, and the patient's response to the intervention. An example of effective nursing action documentation is 'Administered 500 mg of acetaminophen orally for headache at 11:00 am; patient reported pain decreased from 6 to 3 on the pain scale within 30 minutes of administration'.

Such documentation is vital for tracking the efficacy of interventions, adjusting care plans, and ensuring a reliable record for future reference. Keeping accurate records of nursing actions helps to paint a complete picture of a patient's care trajectory and provides a basis for evaluating the outcomes.