A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced by disruption of skin surface has the following nursing documentation: "Incision clean, dry, intact. No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from clothing. Verbalizes understanding of wound care and ability to manage at home. Wound healing without complication." This documentation is:
A) an example of charting by exception.
B) evidence of the use of the nursing process.
C) using the problem-oriented medical record (POMR) format.
D) usually entered on a flow sheet for treatments and vital signs.

Question

Quizplus · Accepted Answer

The nursing process is evident in this documentation. Assessment, interventions, and evaluation are all noted.

A Patient with a Nursing Diagnosis of Skin Integrity, Impaired