CH 19 Documenting and Reporting

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? A) The lower extremities B) Lung sounds C) The abdominal area D) Heart rate and rhythm

A

Which is the primary purpose of client records? Communication Reimbursement Legal protection Performance improvement

A

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? data base problem list plan of care progress notes

D

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? It documents assessments on separate forms. It records progress under problems, intervention, and evaluation. It provides and refers to a client's problem by a number. It provides quick access to abnormal findings.

D

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? "A coronary artery bypass graft will benefit your heart." "The CABG procedure will help identify nutritional needs." "A complete ablation of the biliary growth will decrease liver inflammation." "The CABG procedure will help increase intestinal motility and prevent constipation."

A

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records? "The clients' medical records provide data for legal evidence." "I can share the clients' medical records with the health care team." "The clients' medical records are an obstruction to research and education." "The clients' health records should be used to promote reimbursement from insurance companies"

C

A health care facility plans to evaluate and revise the plan of care for a client based on the client's health care records. The physician, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details? A) SOAP charting B) FOCUS charting C) PIE charting D) Narrative charting

A

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? Client's record and occurrence report Occurrence report and critical pathway Critical pathway and care plan Care plan and client's record

A

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

A

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? A never event A variance An audit A sentinel event

B

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

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) Explain that only a paper copy of the health care record can be viewed by the client. C) Review the hospital's process for allowing clients to view their health care records. D) Discuss how the hospital can be fined for allowing clients to view their health care records.

C

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 will give me a better sense of what my workload will be today." C) "It makes our client feel like we care, especially if we start the day off with a clean room." D) "It will allow for us to see the client and possibly increase client participation in care."

D

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

D

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legally defensible charting? A) Use abbreviations wherever possible. B) Leave spaces between entries and signature. C) Record all facts and subjective interpretations. D) Ensure that the client's name appears on all pages.

D

x 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? Talking directly to the translator facilitates the transfer of information. Talking loudly helps the translator and the client understand the information better. It is always okay to not use a translator if a family member can do it. Translators may need additional explanations of medical terms.

D

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

B

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? 1 Unit of glucose 1 bottle of glucose One U of glucose 1U of glucose

A

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? The nurse can accept verbal orders to provide immediate care and record once the client is stable. The provider can input orders remotely into the EHR system for the nurse to retrieve. The nurse can implement care once written orders are received from the provider. The client must be stabilized before the nurse can obtain any orders from the provider.

A

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? A) Reporting B) Documentation C) Verification D) Dialogue

A

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? A) Documenting clients' health histories and discharge planning B) Recording nursing interventions C) Omitting clients' responses to nursing interventions D) Identifying nursing diagnoses or clients' needs

C

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? Write a narrative note in the designated nursing section. Place the narrative note chronologically after the respiratory therapist's note. Review the laboratory results under the health care provider section. Use a critical pathway to document the physical assessment.

A

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? Subjective data should be included when documenting. Objective data are what the client states about the problem. The plan includes interventions, evaluation, and response. Abnormal laboratory values are common items that are documented.

A

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? Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." Client states expecting some pain, but it is more severe than anticipated. Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. Client is requesting pain medications, is grimacing, and is diaphoretic.

A

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and: reimbursement. staff development. research. change of mechanisms.

A

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? "Any information that can identify a person is considered a breach of client privacy." "You may continue to post about a client, as long as you do not use the client's name." "All aspects of clinical practice are confidential and should not be discussed." "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."

A

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? A) 1U of glucose B) 1 bottle of glucose C) 1 Unit of glucose D) One U of glucose

C

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? The client reports waking up this morning with a severe headache. The client has symptoms in the morning associated with a heart attack. The client is coughing and experiencing severe heartburn in the morning. The client has a history of severe complaints in the morning.

A

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? Inform the health care provider that a written order is needed. Write the order in the client's record. Call the pharmacy to have the order entered in the electronic record. Add the new order to the medication administration record.

A

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? Inform the health care provider that a written order is needed. Write the order in the client's record. Call the pharmacy to have the order entered in the electronic record. Add the new order to the medication administration record.

A

The nurse is documenting a progress note that relates to a client's health problem. What form of documentation is the nurse writing? PIE note flow sheet narrative note SOAP note

D

In SBAR, what does R stand for? A) Response B) Report C) Recommendations D) Reinforcing data

C

A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse likely document the results? progress note admission nursing assessment graphic sheet medical record

C

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? Review the hospital's process for allowing clients to view their health care records. Access the health care record at the bedside and show the client how to navigate the electronic health record. Discuss how the hospital can be fined for allowing clients to view their health care records. Explain that only a paper copy of the health care record can be viewed by the client.

A

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

A

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? Incident report Nurse's shift report Transfer report Telemedicine report

A

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? "I will arrange access for you to review the record after you put your request in writing." "No, the health care provider will not give you access to review the records." "Are you questioning the care of your child?" "Only the client has the right to review the health care records."

A

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

A

Which note includes all elements of a SOAP note? Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness. Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess.

A

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 provides and refers to a client's problem by a number. B) It documents assessments on separate forms. C) It provides quick access to abnormal findings. D) It records progress under problems, intervention, and evaluation.

C

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1"I don't feel well. I've been urinating often, and it burns when I urinate." 2Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. 3Fever, possible urinary tract infection 4Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

ABCD

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method? Source-oriented method PIE charting method Problem-oriented method Focus charting method

B

A nurse is documenting a client's care in the electronic health record. This is the third entry being made by the nurse for the day. The nurse would sign the entry using which signature? Jane Smith, RN J. Smith, RN Jane Smith JS

B

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error? Immediately delete the incorrect documentation. Create an addendum with a correction. Contact information technology (IT) staff to make the correction. Contact the health care provider.

B

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing? FOCUS charting SOAP charting PIE charting narrative charting

B

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

B

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records Making the names of clients on charts visible to the public

B, C, and D

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) Problem list B) Data base C) Progress notes D) Plan of care

C

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records? Problem-oriented recording gives clients the right to withhold the release of their information to anyone. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Problem-oriented recording has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care.

C

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: A) Using only those abbreviations that are defined in full at another location in the client's chart. B) Ensuring that abbreviations are understandable to clients who may seek access to their health records. C) Limiting abbreviations to those approved for use by the institution. D) Using only abbreviations whose meaning is self-evident to an educated health professional.

C

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

C

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

C

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

C

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? "I am concerned that the client might be exhibiting sepsis." "The client's temperature has been 102°F (38.9°C) for the last 6 hours." "The client was admitted today with a urinary tract infection." "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

D

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records? A) Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. B) Problem-oriented recording has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care. C) Problem-oriented recording gives clients the right to withhold the release of their information to anyone. D) Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

D

The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states: A) The rationale is deleted to provide additional charting space in the computer system. B) The use of rationales is not commonly practiced in the clinical setting. C) Rationales are only important while the nurse is in training. D) Although not written, the nurse must know or question the rationale before performing an action. E) Some facilities do not require them on their plans of care.

D

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best? "The UAP will tell me what the vital signs are, and I will record them in the record so the health care provider can review them." "Vital signs do not need to be recorded unless they are abnormal." "The UAP logs in under my name and documents the vital signs." "The UAP is able to log in and enter the information so all members of the health care team can see it."

D

What dual purpose does an audit serve? communication and evaluation knowledge and quality education and confidentiality quality assurance and reimbursement

D

When the home care nurse visits a client, who is recently widowed, the nurse finds that the home is cluttered with trash. The client appears sad and disheveled. Which action would the nurse take based on the assessment findings? Call the health department. Clean up the house. Move the client to an assisted living facility. Refer to the health care provider.

D

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) Nurses should not refer to the names of physicians. D) Precise measurements should be used rather than approximations.

D