Baseline information about the patient is provided by which document?

Baseline information about the patient is provided by which document?

• A. History and physical examination form.
• B. Nursing assessment notes.
• C. Discharge summary.
• D. Baseline information is documented here.

Answer: (B)

Baseline information is the initial set of data about a patient used to compare future changes during care. The nursing assessment notes are the primary place where this baseline is captured and continually updated. Nurses perform the admission assessment to record initial vitals, mental status, pain level, functional status, allergies, current medications, nutrition, sleep, mobility, and skin condition, and they keep updating these findings with each shift. This creates a clear reference point for detecting any subsequent changes in the patient’s condition, guiding ongoing care decisions. While a history and physical examination form often documents useful medical history and the physician’s initial exam at admission, it isn’t the nursing-record baseline that teams rely on for day-to-day monitoring. A discharge summary appears at the end of care to summarize what happened and outcomes, not to provide the ongoing baseline data used during treatment. The option stating that baseline information is documented somewhere other than a nursing assessment notes isn’t a standard source for the patient’s ongoing baseline data.

Baseline information is the initial set of data about a patient used to compare future changes during care. The nursing assessment notes are the primary place where this baseline is captured and continually updated. Nurses perform the admission assessment to record initial vitals, mental status, pain level, functional status, allergies, current medications, nutrition, sleep, mobility, and skin condition, and they keep updating these findings with each shift. This creates a clear reference point for detecting any subsequent changes in the patient’s condition, guiding ongoing care decisions.

While a history and physical examination form often documents useful medical history and the physician’s initial exam at admission, it isn’t the nursing-record baseline that teams rely on for day-to-day monitoring. A discharge summary appears at the end of care to summarize what happened and outcomes, not to provide the ongoing baseline data used during treatment. The option stating that baseline information is documented somewhere other than a nursing assessment notes isn’t a standard source for the patient’s ongoing baseline data.