Which actions should the nurse take before making an entry in a clients record select all that apply

-"I don't feel well. I've been urinating often, and it burns when I urinate."

-Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago.

-Fever, possible urinary tract infection

-Notify Dr. Phillips of fever and client complaints.
Encourage fluids, continue to monitor temperature.

Explanation:
When using the SOAP format, the nurse would first document the subjective data (S: the client's complaint), objective data (O: abdomen, urine characteristics, temperature and contributing factors), assessment (A: caregiver's judgment about the situation—fever and possible urinary tract infection), and plan (P: what the caregiver is going to do—notify the physician, encourage fluids, and continue to monitor).

Source-oriented

Explanation:
A source-oriented record is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically, with the most recent entry being nearest the front of the record. Problem-oriented medical record (POMR) or problem-oriented record is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. PIE charting system is unique in that it does not develop a separate care plan. The care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified). In this documentation system, a client assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms (flow sheets). Client problems identified in these assessments are numbered, documented in the progress notes, worked up using the problem, intervention, evaluation (PIE) format, and evaluated each shift. Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes.

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Which is the proper way to document midnight in a clients record?

Which of these involves charting information about the client and client care in chronological order?

What is the primary purpose of the client record?

Which information should be included as handoff information for new client admissions?