Documentation/Electronic Health Record 2025-2026 Updated Test
BSN 346 - Concepts of Nursing III - January 2025, 20251bsn34606
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Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Flowsheets Documentation
Objective Data Collection
Nursing Note
Education & Empathy
Education Activity Student Documentation Model Documentation
Documentation
Chelsea’s current condition is stable. She is feeling better
Patient Status
Care Plan than she has been lately. No current nausea or vomiting.
Chelsea is alert and curious, and expressed an eagerness
(No Documentation Made) to go home. She said that she has not administered her
own insulin yet, or done her own glucose monitoring.
Chelsea had diabetic ketoacidosis two days prior. She was
at a horseback riding lesson and started feeling nauseated;
when her dad picked her up she threw up in his car. That
evening, Ned said that his daughter seemed really out of it
and was not acting like herself. He brought her to the ED,
and she was diagnosed with DKA and type 1 diabetes.
History of Present Illness
Chelsea’s blood glucose is more stable now. Prior to the
(No Documentation Made) DKA, Chelsea said she felt sick for about 10 days. Her dad,
Ned, said that she lost five pounds in the two weeks since
he’s seen her. She experienced increased thirst and
increased urination / a higher volume of urine during the 10
days leading up to her DKA. Chelsea said her mother
thought she was “going through a growth spurt” or coming
down with a cold.
Chelsea expressed some confusion about the
Assess Patient Knowledge
pathophysiology of type 1 diabetes. She said she had not
done her own insulin administration or glucose monitoring.
(No Documentation Made) Her father also expressed some misunderstandings over
carbohydrates.