When should a nurse document a change in a patient's care plan?

Prepare for your UWorld Leadership Test. Utilize flashcards and multiple choice questions, with comprehensive hints and explanations. Ace your exam!

Documenting a change in a patient's care plan is crucial for maintaining accurate and up-to-date medical records. A nurse should document a change particularly after identifying abnormalities during assessments, such as vital signs. This is because the assessment findings can indicate a need for immediate adjustments in the care plan to address the patient's current health status and ensure appropriate interventions are applied.

When vital signs are assessed and show abnormalities, it could signal a change in the patient's condition that requires an updated approach or intervention. Timely documentation ensures that all members of the healthcare team are aware of the patient's status and can make informed decisions about the ongoing care strategy.

The other scenarios referenced do not necessarily require a change to the care plan or immediate documentation. For instance, a verbal order from a physician might not yet be implemented, and changes based solely on a patient's request may need further evaluation before adjusting the care plan. Documenting improvements after an intervention is also essential but does not necessarily imply the need to change the care plan; it may simply indicate the effectiveness of current interventions. Hence, assessing vital signs and discovering abnormalities is a definitive trigger for documenting a necessary change.

Subscribe

Get the latest from Examzify

You can unsubscribe at any time. Read our privacy policy