Ch 19: Documenting and Reporting

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a) a client who is homebound and needs skilled nursing care b) a client whose rehabilitation potential is not good c) a client whose status is stabilized d) a client who is not making progress in expected outcomes of care

a) a client who is homebound and needs skilled nursing care

What dual purpose does an audit serve? a) communication and evaluation b) knowledge and quality c) education and confidentiality d) quality assurance and reimbursement

d) quality assurance and reimbursement

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence? a) Notifying the nursing team of the client's condition b) Documenting client data on the flow sheet c) Keeping an accurate medication record d) Accurately documenting client care on the client record

d) Accurately documenting client care on the client record

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: a) factual statement. b) interpretation of data. c) important information. d) relevant data.

b) interpretation of data.

Besides being an instrument of continuous client care, the client's health care record also serves as a(an): a) assessment tool. b) legal document. c) Kardex. d) incident report.

b) legal document.

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? a) Client's record and occurrence report b) Occurrence report and critical pathway c) Critical pathway and care plan d) Care plan and client's record

a) Client's record and occurrence report

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report? a) Nurse's shift report b) Transfer report c) Telemedicine report d) Incident report

d) Incident report

Which is the proper way to document midnight in a client's record? a) 0000 b) 2401 c) 1200 d) 1201

a) 0000

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? a) "Let me get that for you." b) "Only authorized persons are allowed to access client records." c) "The provider will need to give permission for you to review." d) "I am sorry I can't access that information."

b) "Only authorized persons are allowed to access client records."

Which abbreviation is correct for use in documentation? a) Sub q b) PO c) Per os d)BT

b) PO

Which documentation tool will the nurse use to record the client's vital signs every 4 hours? a) acuity charting forms b) a flow sheet c) a medication record d) a 24-hour fluid balance record

b) a flow sheet

In SBAR, what does R stand for? a) Reinforcing data b) Response c) Recommendations d) Report

c) Recommendations

Which finding from a nursing audit reflects high standards for client safety and institutional health care? a) The nurse records inappropriate nursing interventions. b) The nurse fails to identify the nursing diagnoses or clients' needs. c) The nurse documents clients' responses to nursing interventions. d) The nurse fails to adequately complete data on clients' health e) histories and discharge planning.

c) The nurse documents clients' responses to nursing interventions.

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan? a) data base b) problem list c) plan of care d) progress notes

d) progress notes

According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? a) Documentation b) Accreditation c) Psychomotor skills d) Clinical judgment

a) Documentation

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? a) SBAR b) SOAP c) PIE d) MAR

a) SBAR

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? a) Finding the emergency medical technicians who transported the family members and inquiring about the injuries b) Calling the client information desk to find out the room number of the family member c) Asking the emergency department nurse for information on the family member d) Accessing the electronic health record of the family member to find out extent of injury

b) Calling the client information desk to find out the room number of the family member

The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? a) Access the health care record at the bedside and show the client how to navigate the electronic health record. b) Review the hospital's process for allowing clients to view their health care records. c) Discuss how the hospital can be fined for allowing clients to view their health care records. d) Explain that only a paper copy of the health care record can be viewed by the client.

b) Review the hospital's process for allowing clients to view their health care records.

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? a) Disclosing client health information for research purposes after obtaining permission from the client's physician b) Releasing the client's entire health record when only portions of the information are needed c) Submitting a written notice to all clients identifying the uses and disclosures of their health information d) Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information

c) Submitting a written notice to all clients identifying the uses and disclosures of their health information

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? a) A client has asked a nurse if he can read the documentation that his physician wrote in his chart. b) A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. c) A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. d) A client who resides in Indiana has required hospitalization during a vacation in Hawaii.

a) A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

Which are high-risk errors in documentation? Select all that apply. a) Inadequate admission assessment b) Failure to document completely c) Charting in advance d) Batch charting e) Falsifying client records

a) Inadequate admission assessment b) Failure to document completely c) Charting in advance e) Falsifying client records

Which example may illustrate a breach of confidentiality and security of client information? a) The nurse provides information to a professional caregiver involved in the care of the client. b) The nurse provides information over the phone to the client's family member who lives in a neighboring state. c) The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. d) The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell.

b) The nurse provides information over the phone to the client's family member who lives in a neighboring state.

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response? a) "According to HIPAA, medical records cannot be changed." b) "HIPAA legislation allows for you to change any information." c) "According to HIPAA legislation, you have a right to request changes to inaccurate information." d) "HIPAA legislation only allows access to review the medical record."

c) "According to HIPAA legislation, you have a right to request changes to inaccurate information."

The nurse hears an unlicensed assistive personel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? a) Remind the UAP about the client's right to privacy. b) Report the UAP to the nurse manager. c) Notify the client relations department about the breach of privacy. d) Document the UAP's conversation.

a) Remind the UAP about the client's right to privacy.

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse? a) "I will arrange access for you to review the record after you put your request in writing." b) "No, the physician will not give you access to review the records." c) "Are you questioning the care of your child?" d) "Only the client has the right to review the health care records."

a) "I will arrange access for you to review the record after you put your request in writing."

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate? a) Explain the reason why information cannot be disclosed. b) Verify the insurance coverage before giving information. c) Refer the parent to the physician providing care. d) Mediate a meeting between the parent and client.

a) Explain the reason why information cannot be disclosed.

What does the nurse recognize as purposes of the electronic health record? Select all that apply. a) documenting continuity of care b) qualifying health care providers for government funds c) ensuring client safety d) facilitating health education and research e) defending health care personnel during practice lawsuits

a) documenting continuity of care b) qualifying health care providers for government funds c) ensuring client safety d) facilitating health education and research

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? a) subjectivity b) objectivity c) organization d) reimbursement

a) subjectivity

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given? a) 0930 b) 2130 c) 930 p.m. d) 1930

b) 2130

A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse best reflects the effectiveness of the pain medication? a) States pain is not relieved, talking with family on phone. b) Rates pain 8/10, states nauseated for last 30 minutes. c) Vital signs within normal limits, sleeping. d) Rates pain higher on pain scale, notified physician.

b) Rates pain 8/10, states nauseated for last 30 minutes.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? a) Write the order in the client's record. b) Call the pharmacy to have the order entered in the electronic record. c) Inform the health care provider that a written order is needed. d) Add the new order to the medication administration record.

c) Inform the health care provider that a written order is needed.

Which principle should guide the nurse's documentation of entries on the client's health care record? a) Correcting fluid is used rather than erasing errors. b) Documentation does not include photographs. c) Precise measurements should be used rather than approximations. d) Nurses should not refer to the names of physicians.

c) Precise measurements should be used rather than approximations.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? a) Dialogue b) Documentation c) Reporting d) Verification

c) Reporting

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? a) The client is receiving sufficient relief from pain medication, stating no pain in either knee. b) The client appears comfortable and is resting adequately and appears to not be in acute distress. c) The client reports that on a scale of 0 to 10, the current pain is a 3. d) The client appears to have a low tolerance for pain and frequently reports intense pain.

c) The client reports that on a scale of 0 to 10, the current pain is a 3.

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR? a) "I am concerned that the client might be exhibiting sepsis." b) "The client's temperature has been 102°F (38.9°C) for the last 6 hours." c) "The client was admitted today with a urinary tract infection." d) "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

d) "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information? a) Client states expecting some pain, but it is more severe than anticipated. b) Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. c) Client is requesting pain medications, is grimacing, and is diaphoretic. d) Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

d) Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

Which statement is not true regarding a medication administration record (MAR)? a) The MAR distinguishes between routine and "as needed" medications. b) The MAR identifies routine times for medication administration. c) After using an electronic MAR, the nurse should log off. d) If the client declines the dose, the nurse does not have to document this on the MAR.

d) If the client declines the dose, the nurse does not have to document this on the MAR.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? a) It documents assessments on separate forms. b) It records progress under problems, intervention, and evaluation. c) It provides and refers to a client's problem by a number. d) It provides quick access to abnormal findings.

d) It provides quick access to abnormal findings.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? a) those directly involved in the client's care b) any family member of the client c) close friends of the client d) health care professionals of the facility

a) those directly involved in the client's care

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? a) "I am calling about the patient in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." b) "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." c) "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." d) "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."

c) "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? a) "It will let me see everything that has been done and things that need to be done." b) "It makes our client feel like we care, especially if we start the day off with a clean room." c) "It will allow for us to see the client and possibly increase client participation in care." d) "It will give me a better sense of what my workload will be today."

c) "It will allow for us to see the client and possibly increase client participation in care."

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client? a) 8:00: Pt is resting in bed and appears to be comfortable. b) 0800: Resting in bed, eating some breakfast. Complains of headache. c) 0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. d) 0800: Side rails up, call light in reach. Bed in high position.

c) 0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate? a) Provide the information to the parent. b) Explain the reasons for the hospitalization, but give no further information. c) Ask the client if information can be given to the parent. d) Take the parent to the client's room and have the client give the requested information.

c) Ask the client if information can be given to the parent.

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? a) "I am calling because the client receiving blood has developed dyspnea and had crackles." b) "This client has a medical history of heart failure." c) "It seems like this client has fluid volume overload." d) "I think the client would benefit from intravenous furosemide."

d) "I think the client would benefit from intravenous furosemide."

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse? a) "It would be easier to do it that way. You could develop a tool to use." b) "The facility requires us to document client care this way because of the computer application used." c) "The electronic health record we use does not allow us to use different formats." d) "Legal policy requires nursing practice to be permanently integrated into the client record."

d) "Legal policy requires nursing practice to be permanently integrated into the client record."

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator? a) Talking directly to the translator facilitates the transfer of information. b) Talking loudly helps the translator and the client understand the information better. c) It is always okay to not use a translator if a family member can do it. d) Translators may need additional explanations of medical terms.

d) Translators may need additional explanations of medical terms.