Chapter 10: Imformatics and Documentation; Table 10.2

Question 1

Subjective Data

Answer 1

• Description of episode in quotations
• Onset, location, description of condition
• Onset, behaviors exhibited, precipitating factors

Question 2

Objective Data

Answer 2

• Onset, location, description of condition

- Changes from baseline

Question 3

Treatments

Answer 3

-Time administered, equipment used, patient’s response, compared with previous treatment

Question 4

Medication Administration

Answer 4

-Immediately after administration, document time medication given, dose, route, any preliminary assessments, patient response or effect of medication

Question 5

Patient Teaching

Answer 5

-Information presented, method of instruction, patient response, including questions and evidence of understanding such as return demonstration or change in behavior

Question 6

Discharge Planning

Answer 6

-Measurable patient goals or expected outcomes, progress toward goals, need for referrals