ATI 7: Documentation

A nurse is reviewing the documentation of a newly licensed nurse. Which of the entries should the nurse identify as meeting the American Nurses Association (ANA) standards of documentation? "The client is now asleep, and they ate most of their breakfast a few hours ago." "The client vomited 240 mL of clear emesis but denies pain or nausea." "The client reports not feeling good, but they look fine." "The client has 8 to 10 sores on their body."

"The client vomited 240 mL of clear emesis but denies pain or nausea"

A nurse is reviewing documentation principals with a group of newly hired assistive personnel (AP). Which of the following should the nurse include? Providers designate to other staff which abbreviations cannot be used. A nurse who delegates a task to an AP will review the charting for that task. Providers read and cosign nursing documentation for accuracy. Licensed personnel should document out-of-range vital signs for AP.

A nurse who delegates a task to an AP will review the charting for that task

A nurse is caring for a client after a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first? (select all that apply) The admitting provider The charge nurse on the unit The client's sibling The client The client's spiritual advisor

A. The admitting provider B. the charge nurse on the unit D. the client

A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information? A. "I can take a telephone prescription if a provider is making routine rounds in another area of the facility." B. "I can take a telephone prescription if a provider is directing a code for an unresponsive client." C. "If a client requires an over-the-counter medication for relief of nausea, it is okay to accept a telephone prescription." D. "If a client requires pain control for a terminal condition, it is okay to accept a telephone prescription."

B. "I can take a telephone prescription if a provider is directing a code for an unresponsive client."

A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication? By mouth Intramuscularly Per rectum Intravenously

By mouth

A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include? A. A problem-oriented medical record is created using the PIE model for documentation entries. B. A problem-oriented medical record contains separate sections for laboratory and diagnostic information. C. A problem-oriented medical record promotes information sharing among members of the interdisciplinary team. D. A problem-oriented medical record is rarely used in acute care settings.

C. A problem-oriented medical record uses progress notes, which promotes information sharing among members of the interdisciplinary team.

A nurse is discussing computerized provider order entry systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE system? "CPOE systems are associated with a slightly higher error rate." "CPOE use does not include medication prescriptions." "CPOE systems can increase the speed of care delivery." "CPOE use is mandated by HIPAA under the Privacy Rule."

CPOE systems can increase the speed of care delivery

A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include? American Nurse Association (ANA) standards prevent client records from being used for legal proceedings. HIPAA regulations vary from one state to another. Privacy regulations apply to electronic data transfer rather than verbal communication. Facilities can establish their own rules for documentation methods.

Facilities can establish their own rules for documentation methods

A nurse is talking with a client about the electronic health record at the facility. Which of the following client statements indicates an understanding of EHRs? "I will be able to track my health information." "My personal information will be entered into a national database." "I will have one EHR that will encompass the health care I've received over my lifetime." "The goal of EHRs is to improve insurance coding."

I will be able to track my health information

A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record? Immunization data Record of client health care payments Complete medical information for household members Facility policies

Immunization data

A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on the joint commissions do not use list? (select all that apply) MSO4 IU PO qhs NKA

MSO4 IU qhs

A nurse in the clinic is reviewing a clients prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed? PRN NPO AC Ad lib

PRN

A newly licensed nurse is orienting to a facilities documentation process. The facility requires staff to on,y document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods? Charting by exception Subjective, objective, assessment, plan format Problem, intervention, evaluation model Data, action, response charting

Charting by exception

A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include? "Accessing the medical record of clients on units other than where you are assigned is allowed." "There are large financial penalties for charting vital signs you obtain for another nurse's client." "Personnel can be terminated for breaching a client's confidentiality." "Once you have cared for a client, it is acceptable to look at their medical record on subsequent health care visits."

Personnel can be terminated for breaching a client's confidentiality

A charge nurse is reviewing soap documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data? The client states, "I've had abdominal pain for the past 3 days." The client reports consuming about 1,500 mL of water per day. Rebound tenderness noted in RLQ of the abdomen. Recommend client referral to a registered dietitian.

Rebound tenderness noted in RLQ of the abdomen

A charge nurse is reviewing characteristics of electronic documentation with staff at a providers office. Which of the following characteristics should the charge nurse plan to include? (select all that apply) Reduces medical errors Improves listening skills among interdisciplinary team members Less convenient than paper-based charting Makes client medical history more easily available Increases accuracy of coding procedures

Reduces medical errors Makes clients medical history more easily available Increases accuracy of coding procedures

A nurse manager is reviewing the documentation of for newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly? Synthroid 100 mg PO every morning ac Enoxaparin 75 mg SQ bid Digoxin 0.25 mg PO qd Metformin 500.0 mg PO with evening meal

Synthroid 100 mg PO every morning ac

A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs. The Institute of Medicine Department of Veteran Affairs American Hospital Association The Joint Commission

The Institute of Medicine (IoM)

A nurse is documenting information in a clients chart and makes the entry quotation mark client reports "abdominal pain on exertion". Which of the following documentation format describes this entry? The "I" in PIE The "S" in SOAP The "R" in DAR The "E" in PIE

The S in soap

A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following should the nurse include as a benefit of electronic documentation? A. The system alerts providers of possible actions that could cause client harm. B. An electronic system prevents breaches of confidentiality of client data. C. Providers can document client information in the electronic record during system downtime. D. System encryption eliminates the need for security firewalls.

The system alerts providers of possible actions that could cause client harm