ch 18
Why might a healthcare provider choose narrative charting instead of using forms or checklists? a) Narrative charting tracks the client's changing health status as it occurs. b) Free form documentation is inconsistent among healthcare providers. c) Less charting time by healthcare provider is needed for narrative charting. d) Less interdisciplinary discussion occurs with the narrative style of charting.
ANS: A A narrative chart entry tells the story of the patient's experience as it occurs in a chronological format with the goal to track a client's changing medical and health status. It also documents progress toward goals for the client. Disadvantages to narrative charting include the following: inconsistency among healthcare providers and the manner in which they document using narrative charting; longer time spent in documenting client progress; and a decrease in interdisciplinary discussion of client progress owing to lengthy and redundant documentation by healthcare team members.
A client is admitted to a long-term care facility. The nurse knows that federal law requires the use of: a) The Minimum Data Set (MDS) for assessment b) Situation-Background-Assessment-Recommendation (SBAR) for reporting c) Health Care Financing Administration guidelines prior to surgery d) The Joint Commission guidelines for discharge planning
ANS: A Federal regulations require that a resident be evaluated using the Minimum Data Set (MDS) within 14 days of admission to a long-term care facility. SBAR is a technique used for communicating and organizing a handoff report. HCFA guidelines govern home healthcare documentation. Joint Commission guidelines do apply to long-term care facilities. However, only the MDS assessment is mandated by federal law.
What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident is of a long-term care facility? a) 14 days b) 3 days c) 2 days d) 24 hours
ANS: A Federal regulations require that a resident be evaluated using the Minimum Data Set within 14 days of admission to a long-term care facility.
The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports? a) "Occurrence reports track problems and identify areas for quality improvement." b) "Occurrence reports are required by the Food and Drug Administration (FDA) to report drug errors." c) "The Joint Commission requires occurrence reports for all client falls." d) "Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence."
ANS: A Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal information should a patient seek legal action. As an internal communication and documentation tool, occurrence reports are not required to be reported to the FDA or The Joint Commission.
The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? a) Repeat the order to the prescriber even if she believes she understood the order correctly. b) Immediately notify the pharmacy of the order and verify it with a pharmacist. c) Ask the unit secretary to listen to the prescriber on the phone to verify the order. d) Transcribe the order on notepaper and verify the dosage in a drug handbook.
ANS: A The nurse should repeat the order to the prescriber even if she believes she understood it entirely. If possible, she should have a second nurse (not the unit secretary) listen to the order to verify accuracy. Only the prescribing provider, not the pharmacist, can verify the order. The nurse should transcribe the order directly on the patient's chart. Transcribing it on a piece of paper and then copying it again introduces one more chance of error.
Which action by the nurse breaches patient confidentiality? Select all that apply. a) Leaving patient data displayed on a computer screen where others may view it b) Remaining logged on to the computer system after documenting patient care c) Faxing a patient report to the nurses' station where the patient is being transferred d) Informing the nurse manager of a change in the patient's condition
ANS: A, B Leaving patient data displayed on a computer screen where others may view them breaches patient confidentiality. The nurse should log off the computer immediately after use. Faxing a report to the nurses' station receiving a patient does not breach patient confidentiality because it is located at the nurses' station out of others' view. Anyone directly involved in the patient's care has the right to know about the patient's condition without breaching patient confidentiality.
In performing a handoff report, the nurse should communicate information on which of the following? Select all that apply. a) Teaching performed b) Any change in client status c) Treatments administered d) Hygiene measures performed
ANS: A, B, C Handoff reports include any client teaching done, therapies and treatments administered, and changes in the client's status. Hygiene care is routinely done in inpatient settings and is usually recorded on a flowsheet. Handoff reports should be succinct and not contain routine information.
Knowing that discharge summary information is integral to the client's ongoing care, which of the point(s) regarding discharge summaries must the nurse be aware? Select all that apply. a) The discharge summary is important because many clients require follow-up care. b) A complete discharge summary is a guide for healthcare professionals in the community. c) The nurse can give a verbal transfer report, which is the same as a discharge summary. d) The discharge summary is the final note in the client's health record e) A complete discharge summary must be handwritten using the narrative note format.
ANS: A, B, D A complete discharge summary must be completed even if a complete verbal transfer report is given to ensure that all important and specific information is communicated to another healthcare provider when the client is discharged from the hospital. It is important for every client for ongoing care and documentation while the client is in the community. A verbal transfer report is not a replacement for the comprehensive discharge record; it can be done in the EMR formats, a narrative note, or on a discharge summary form.
Which statement(s) by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply. a) "I can wait until the end of the shift to document my care." b) "Charting every 2 hours is the most appropriate way to document nursing care." c) "I find it easier to chart before I go to lunch, and then after my shift report." d) "I should chart as soon as possible after nursing care is given."
ANS: A, B, D Documentation should be performed as soon as possible after the nurse makes an assessment or provides care. The longer the nurse waits, the less accurate the documentation will be. Leaving documentation until the end of the shift may cause important details to be omitted or mistaken. It is not necessary to complete documentation on a strict schedule, such as every 2 to 4 hours. Even waiting until lunch or report after the shift is over is too long a period of time for accurate documentation. In addition, the objectivity of documentation might be influenced by the discussion that occurs during report.
The implementation of electronic health records (EHRs) allows the nurse to do which of the following? Select all that apply. a) Use trend data to facilitate evidence-based nursing practice b) Promote efficient use of time spent charting c) Reduce the opportunity for interdisciplinary collaboration d) Activate the system's safeguards to promote client safety
ANS: A, B, D The implementation of electronic health records (EHR) has many advantages for the nurse. These include the ability to identify trends in data to facilitate evidence-based nursing practice, promote the efficient use of the time nurses spend documenting client care, and use the system's safeguards to minimize errors in clients care. EHR does not impair interdisciplinary collaboration; rather, EHR fosters communication and collaboration among healthcare team members.
Which statement(s) by the student nurse indicates an understanding of the nursing Kardex? Select all that apply. a) "It pulls data from multiple areas of the patient's chart." b) "It is usually kept at the patient's bedside." c) "It is used to document patient response to interventions." d) "It summarizes the plan of care and guides nursing care."
ANS: A, D The Kardex is a tool that pulls data from multiple areas of the patient's health record and helps guide nursing care. Responses to interventions are documented on flowsheets and in nurses' notes. Kardexes are paper forms that are kept together in a portable file at the nurses' station to allow all team members access to the summary information. The file is portable, so it could be carried to the bedside briefly; however, it is not stored there as a general rule.
A patient refuses a dose of medication. How should the nurse document the event? a) Patient is uncooperative and refuses the prescribed dose of digoxin. b) Patient refuses the 0900 dose of digoxin. c) Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. d) 0900 dose of digoxin not given.
ANS: B "Patient refuses the 0900 dose of digoxin" objectively describes the event in which the patient refuses to take his 0900 dose of digoxin. "0900 dose of digoxin not given," provides no explanation why the medication was not given. The other two options offer judgmental information, which should be avoided when charting.
A medical provider has prescribed milk of magnesia (magnesium hydroxide) 30 mL, PO bid. Here bid means: a) Once every day b) Two times every day c) Three times every day d) Four times a day
ANS: B Bid is the abbreviation for twice a day, which is generally 12 hours between doses. Once a day is written as "daily": every hour is abbreviated qh, three times a day is tid and four times a day is qid. Abbreviations are used with caution to reduce error(s) by the nurse and the healthcare teams. The abbreviation qd is not used for once a day, but is written as "daily."
The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall. a) Patient found on floor after falling out of bed and verbalizes (L) hip pain. b) Patient found on floor by NAP Smith and verbalizing (L) hip pain. c) Patient fell out of bed but is currently in bed. d) Patient reminded not to climb OOB after falling.
ANS: B Charting must be accurate and succinct. Only chart what you observe. Do not chart what others have observed as your own observation. Avoid judging patients; instead, chart objectively.
The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone prescription for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order? a) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain. Kay Andrews, RN b) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN c) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain V.O.: Dr. D. Kelly/Kay Andrews, RN d) 09/02/16 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN
ANS: B Correct documentation of a telephone order is as follows: "09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN" (date, time, medication, route, frequency of dose, circumstances under which it is to be given, prescriber's name and title, nurses name and title.) The other options demonstrate incomplete documentation of a telephone order.
The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeon's order? The nurse: a) Performs oral care b) Assists the patient out of bed c) Assists the patient with bathing d) Changes the patient's operative dressings
ANS: B OOB is the abbreviation for "out of bed." The nurse is following the physician's order when she assists the patient out of bed in the morning. OOB does not indicate that the nurse should perform oral care, assist with bathing, or change the patient's postoperative dressings.
At the end of a 12-hour shift, the nurse gives a verbal report to the oncoming nurse. This face-to-face reporting, using the acronym "CUBAN," does which of the following? a) Ensures that the nurse is able to finish the shift as quickly as possible b) Provides a guide for the nurse's report to the oncoming nurse c) Requires the nurses to engage in walking rounds for the report d) Provides a detailed cultural report for Latino patients
ANS: B The CUBAN acronym is used in all types of report formats and stands for Confidential, Uninterrupted, Brief, Accurate, Named nurse. Following this format, the nurse giving report has a guide to remember the important data that need to be shared with the oncoming nurse who will care for the patient. Report should not be rushed in order for a nurse to finish the shift as quickly as possible. However, the nurse should try to begin report before the shift is over, early enough to complete report before the next shift begins. The CUBAN approach does not require walking rounds. The CUBAN acronym can be used for report about any patient regardless of race, ethnicity, or religion and does not necessarily provide cultural information. It is not specific to Latino patients.
Which prescription below is not consistent with the standards established by The Joint Commission? a) Administer Lasix 20 mg PO daily at 1000. b) Administer Lasix 10.0 mg PO daily at 1000. c) Administer digoxin 10 mg PO daily at 1000. d) Administer digoxin 0.3 mg IV daily at 1000.
ANS: B The Joint Commission recommends that certain words are written out instead of using symbols and abbreviations to minimize the risk of medication errors. The trailing zero should not be used in medication prescriptions; thus, 10.0 mg is incorrect. It should be correctly written as 10 mg. The word daily should be used in place of qd or q.d., as is done in all the options. The Joint Commission does not support the lack of a leading zero; thus, 0.3 mg is correctly written.
The electronic health record (EHR) is used to document client care management. Which statement(s) below is/are applicable to EHR? Select all that apply. a) Increases the potential for breaches in confidentiality b) Decreases the time spent to complete documentation c) Minimizes medical errors through use of alert systems d) Communicates the client's plan of care to the healthcare team
ANS: B, C, D The EHR streamlines many documentation steps, making written communication concise and standardized. Electronic access to the patient's health record increases confidentiality and security of information by using customized passwords for each healthcare professional to limit access to the records. Time for documentation is decreased as the nurse becomes more comfortable using electronic documentation. Medical errors are decreased owing to programmed alerts that are automatically displayed when a healthcare provider takes an action that could potentially be harmful to the client. The EHR facilitates communication of client care across the healthcare team because all of the information is in one place and multiple people can access it from different computers at the same time.
A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system? a) It involves a cooperative effort among various disciplines. b) The system requires diligence in maintaining a current problem list. c) Data may be fragmented and scattered throughout the chart. d) It allows the nurse to provide information in an unorganized manner.
ANS: C A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. The problem-oriented medical record requires a cooperative effort among disciplines and diligence in maintaining a current problem list. Narrative charting allows the nurse to provide information in a disorganized manner.
A client is admitted to the birthing unit to rule out preterm labor. The nurse charts only abnormal findings. This type of charting is a form of: a) Narrative charting b) Charting by inclusion c) Charting by exception d) Source oriented charting
ANS: C Charting by exception is a system of charting where only exceptions to the normal findings or to the unit standards are charted. These are directed by organizational, professional, and legal guidelines. Narrative charting records all findings, normal and abnormal. Charting by inclusion is not discussed in the text. Source-oriented charting refers to each healthcare practitioner's charting in a specific section of the chart. For example, nurses would document in the nurses' notes section and physicians would document in the physician section of the healthcare record.
Which of the following is the most beneficial aspect of electronic documentation systems? a) Assist collaboration b) Provide cautionary reminders c) Improve legibility d) Serve as a resource
ANS: C One of the most beneficial aspects of electronic documentation systems is its ability to improve legibility, which reduces the risk for medication administration and other errors. Electronic documentation systems also assist collaboration, provide cautionary reminders about possible adverse reactions, and serve as a resource; but these are not the most beneficial aspects.
Which set of topics makes up a handoff report given in a recommended format? a) Data-action-response (DAR) b) Subjective-objective-assessment-plan (SOAP) c) Situation-background-assessment-recommendation (SBAR) d) Patient-diagnosis-medications-activity
ANS: C The SBAR technique is used as a mechanism to give a handoff report by enabling a focused communication between healthcare team members. DAR is used in Focus Charting®, SOAP is a method for documenting nursing care. The nursing admission assessment is completed and documented at the time of admission.
A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery, a colon resection, for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement? a) Hypertension b) Rheumatoid arthritis c) Postoperative colon resection d) Follow all three plans
ANS: C The postoperative colon resection integrated plan of care should be followed; however, modifications should be made to meet the patient's other health needs. Therefore, portions of the hypertension and rheumatoid arthritis integrated plan of care may be added to the postoperative colon resection plan of care, or individualized nursing diagnoses and interventions may be integrated into the plan.
At 1000 on 11/14/16, the nurse takes a telephone prescription for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order? a) 11/14/16 at 1200 b) 11/14/16 at 2200 c) 11/15/16 at 1000 d) 11/16/16 at 1000
ANS: C The prescriber must countersign all verbal and telephone orders within 24 hours.
The nurse is administering the 0900 dose of heparin 5,000 units subcutaneously ordered every 6 hours to a patient with deep vein thrombosis (DVT). At 0800, the patient's laboratory values show partial thromboplastin time (PTT) and clotting times are four times the normal range. The nurse observes petechiae on the patient's buttocks and back and recognizes these as signs of risk for significant bleeding. The correct nursing actions at this time are below. Select all that apply. a) Notify the prescriber before giving the medication. b) Give subcutaneous heparin as ordered. c) Hold the medication dose at this time. d) Chart the reason the medication was not given. e) Assess for other significant signs and symptoms. f) Record abnormal findings in the patient's health record.
ANS: C, D, E, F Heparin, an anticoagulant, should be given to achieve one and a half to two times the normal clotting times and PTT. Because the findings of the laboratory values are four times the normal range and petechiae are present, this indicates a significant risk for bleeding. Therefore, the heparin should be held; the physician should be notified immediately. The nurse must document why the medication was not given and should assess for other significant findings. Omitted or delayed administration must be charted as soon as possible with an explanation for the delay or omission. The nurse will notify the provider but not give the medication. Heparin is given via a subcutaneous injection; however, because it is being held, it will not be administered or documented as "given." Because the findings regarding the heparin and its use are abnormal, the nurse would not document normal findings.
The department of nursing at a local hospital is considering changing to charting by exception (CBE). A major disadvantage of CBE is that it: a) Increases the time nurses spend on charting in narrative format b) Does not clearly identify deviations from normal expectations c) Requires all providers to document in the same sections of the chart d) Can increase the risk of omissions in patient care
ANS: D A major disadvantage of CBE is that it can result in omissions in documenting client care because of either varying views of what is abnormal or deviations. Another disadvantage is that is does not capture the application of critical thinking by the nurse in the provision of care. CBE reduces the amount of time spent in charting because if nurses document only deviations from the normal CBE, then it is assumed that unless a separate entry is made, all standards have been met with a normal response.
A student nurse makes the following comments to her preceptor: "I love getting information from the chart. Everything related to the patient's problem is together and addressed by various members of the healthcare team." The student nurse has been introduced to which type of charting system? a) Narrative b) Focus c) Source oriented d) Problem oriented
ANS: D Narrative charting is a free text description of the patient status and nursing care, not usually organized according to patient problems. Focus charting highlights the patient's concerns, problems, and strengths in a three-column format. Source-oriented record systems require members of each discipline to record their findings in a separately labeled section of the chart. A problem-oriented record system is organized around the patient's problems and each member of the healthcare team document in the area designated for that problem. This method makes it easier to view the patient's progress and integrate the interdisciplinary perspective.
The instructor is teaching the nursing students about electronic health records (EHR). Which student statement indicates the need for further instruction? a) "I have had EHR instruction and understand the basics of the system. If I need assistance, I will ask for it." b) "The EHR integrates the patient's health information documented by the entire healthcare team into one electronic system." c) "The EHR can track problems and errors, which can direct quality improvement efforts in a given institution." d) "I am proficient with a computer; therefore, I am completely prepared to use the EHR in any institution."
ANS: D The EHR can vary according to institution and is employed through integrative technology for the entry of data from all healthcare professionals. Although a student knows how to use a computer, this knowledge may not directly translate so that the student is able to accurately document in any particular institution. A person needs to be taught the specifics of each system. A student who understands that even though the system has been taught to him also knows that the instructor will be a resource for EHR questions that may arise. The EHR generally integrates information to be used by the healthcare team. Data can be collected and analyzed multiple ways to evaluate and improve patient care.
A resident in a long-term care facility is unable to provide self-care owing to dementia and is receiving Medicare funds. How often must the nurse document this resident's care? a) Every 2 weeks b) Every shift c) Every week d) Every 3 months
ANS: D The Minimum Data Set for Resident Assessment and Care Screening (MDS) must be updated every 3 months, unless there is a significant change in the resident's condition.
What is one advantage of problem-intervention-evaluation (PIE) charting? a) Focuses on a complete list of client problems b) Assesses the client in a comprehensive manner c) Documents the planning portion of the client's care d) Establishes an ongoing plan of care for the client
ANS: D The PIE charting format organizes information by the client's problems and requires a daily assessment record and progress notes, thus eliminating the need for a nursing care plan. It documents, in a comprehensive manner, the client information. It does not assess the client.
A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client's condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first? a) Study the discharge plan. b) Check the graphic data for vital signs. c) Examine the history and physical examination. d) Look for an advance directive.
ANS: D The advance directive, which should be located in a special section of the patient's medical record, should be examined first because the patient's symptoms indicate that he may need to be resuscitated. The advance directive contains information about the patient's wishes for intensity of care and actions that should be taken in the event of a life-threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data record assessment should be done frequently, such as vital signs. The history and physical examination provide a detailed summary of the patient's current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data.
Which instruction by a registered nurse should the student nurse clarify with her clinical instructor? "When taking off the provider's orders, you should: a) Write drug names in full—rather than using abbreviations" b) Use apothecary units—instead of metric units" c) Write 'at' or 'each'—rather than use the '@'symbol" d) Write 'mL' or 'milliliters'—in place of the 'cc' abbreviation"
NS: B The student nurse should question the instruction to use apothecary units—instead of metric units. Nurses are encouraged to use metric units instead of the rarely used apothecary system.
