The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
A) Narrative notes
B) SOAP notes
C) Focus charting
D) Charting by exception
Ans: A
One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.
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Northwestern Hospital has decided to implement peer review. As a clinical leader in the Emergency Department, you have overall responsibility for ensuring that this is in place by next month. The most important step in this process is to:
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