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Where does the nurse describe the nursing care given?

a. admission record
b. ADL flow sheet
c. Progress notes
d. Kardex

1 Answer

4 votes

Final answer:

The nurse describes the given nursing care in the progress notes, which include detailed records of procedures, counts, specimen labeling, and equipment issues.

Step-by-step explanation:

The nurse typically describes the nursing care given in the progress notes. These notes are an essential part of the patient’s medical record, providing a detailed account of the care provided, the nursing assessment, interventions, and any changes in the patient's condition. Progress notes serve as a communication tool among healthcare providers where the nurse captures important data, including but not limited to the name of procedures performed, the completion status of needle, sponge, and instrument counts, labeling of specimens with the patient's name, and any equipment issues that need to be addressed. This documentation ensures continuity of care and legal protection for the nursing staff and the healthcare facility.

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