A nurse has been caring for a client in a healthcare facility. Which document would be most helpful in determining the client's ability to perform activities of daily living?
A) Medical information systems (MIS)
B) Medical administration record (MAR)
C) Resident assessment protocol (RAP)
D) Charting by exception (CBE)
C
Feedback:
A resident assessment protocol, or RAP, will help the nurse in identifying functional losses affecting the client's ability to perform activities of daily living. An MIS or medical information system is used for storing, processing, and transmitting client data, treatment strategies, and outcomes over a computer network. It is a method for keeping electronic records. A medication administration record, or MAR, is a progress record that lists all medications that the physician has ordered for the client, with spaces for the caregiver to mark when medications are given. Charting by exception, or CBE, is a system that uses a flow sheet that identifies excepted assessments, and a progress note to identify abnormalities or unexpected findings.
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