
Concept explainers
1.
To match:
The line of documentation with appropriate SOAP category.
- a. Subjective (S)
Concept introduction:
The documentation is one of the important practices in the nursing care plan as well as for hospital procedure for patient information that are legalized. The documentation by the nurse gives important information about the patient. The documentation will be in the form of medical records, nursing records, and handing-over documents. The medical record holds the information about the patient what type of disease the patient suffering. The nursing records contain the in-ward documents from the time the patient got admitted, records of the patient vitals, medicines are taken, and till the time of discharge. The informatics in nursing aids in the documentation, research, education, and administration.
2.
The line of documentation with appropriate SOAP category.
- b. Objective (O)
Concept introduction:
The documentation is one of the important practices in the nursing care plan as well as for hospital procedure for patient information that are legalized. The documentation by the nurse gives important information about the patient. The documentation will be in the form of medical records, nursing records, and handing-over documents. The medical record holds the information about the patient what type of disease the patient suffering. The nursing records contain the in-ward documents from the time the patient got admitted, records of the patient vitals, medicines are taken, and till the time of discharge. The informatics in nursing aids in the documentation, research, education, and administration.
3.
To match:
The line of documentation with appropriate SOAP category.
- c. Assessment (A)
Concept introduction:
The documentation is one of the important practices in the nursing care plan as well as for hospital procedure for patient information that are legalized. The documentation by the nurse gives important information about the patient. The documentation will be in the form of medical records, nursing records, and handing-over documents. The medical record holds the information about the patient what type of disease the patient suffering. The nursing records contain the in-ward documents from the time the patient got admitted, records of the patient vitals, medicines are taken, and till the time of discharge. The informatics in nursing aids in the documentation, research, education, and administration.
4.
To match:
The line of documentation with appropriate SOAP category.
- D. Plan (P)
Concept introduction:
The documentation is one of the important practices in the nursing care plan as well as for hospital procedure for patient information that are legalized. The documentation by the nurse gives important information about the patient. The documentation will be in the form of medical records, nursing records, and handing-over documents. The medical record holds the information about the patient what type of disease the patient suffering. The nursing records contain the in-ward documents from the time the patient got admitted, records of the patient vitals, medicines are taken, and till the time of discharge. The informatics in nursing aids in the documentation, research, education, and administration.

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Chapter 26 Solutions
Fundamentals of Nursing, 9e
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- Anything else I should add to this slide and notes? Can you also put the notes into paragraphs with the changes?arrow_forwardAnything else I should add to this slide? Can you also put the notes into paragraphs?arrow_forwardMake a nursing care plan include cognitive goal, affective goal, psychomotor goal, cognitive, affective, psychomotor interventions, and rationale for each Cognitive (Independent Interventions) Cognitive (Dependent Interventions) Cognitive (Collaborative Interventions) Affective (Independent Interventions) Affective (Dependent Interventions) Affective (Collaborative Interventions) Psychomotor (Independent Interventions) Psychomotor (Dependent Interventions) Psychomotor (Collaborative Interventions) Nursing Diagnosis: Acute pain related to post operative surgery as evidenced by guarding and facial grimace Chief Complaints: Hypogastric pain history of present illness2 months prior to consultation the patient complained of abdominal pain associated with discomfort, she was admitted to the ER but was discharged with unrecalled medications. 1 month prior to consultation the patient had moderate to severe dysmenorrhea, a whole abdominal ultrasound was performed and the results indicated…arrow_forward
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- 3.14 3.10 ha 3.11 3.12 3.13 سل سل مه سه له اسم اسم الاسهم السد 3.15 سىلىلىarrow_forward3.3 3.2 سل Regularity: Rate: P Waves: PRI: QRS: 3.4 3.5 2982 MOR MAMAORI DRSHTADTHAMarrow_forwardProblem solving process: List and identify each step within the problem-solving process. Select and summarize any recent or hypothetical health care management scenario that analyzes the responsibilities of the health care leader. In the scenario, you may wish to consider the following: Responsibilities of the health care leader Actions taken to complete the identified steps and effectiveness of the decisions made by the health care leaderarrow_forward
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