Chapter 10 - Documentation

During the change-of-shift report, the nurse reports that the client is having "respiratory difficulty".What should the nurse add to this report? 1. "But she seems okay." 2. "Her respiratory rate is up to 28 breaths/min; oral temperature is 100 degrees; heart rate is 96 beats/minute; O2 saturation of 90%." 3. "I put her on 3 liters of oxygen." 4. "I called the doctor but he didn't do anything."

"Her respiratory rate is up to 28 breaths/min; oral temperature is 100 degrees; heart rate is 96 beats/minute; O2 saturation of 90%." When giving the change-of-shift report, the nurse should use a guide, begin by giving background information of the client, be specific, describe abnormal findings and provide supporting evidence.

Which one of the following is the most correct notation for the nurse to make in the record? a. "Dr. Green made an error in the amount of medication to administer, so recalculation was done." b. "Verbalized sharp pain to lower right side of the abdomen." c. "Nurse Barber spoke with the patient about the diet." d. "The patient was upset with the respiratory therapist."

"Verbalized sharp pain to lower right side of the abdomen." Accurate and detailed information

Which client will require more frequent documentation by the nurse? 1. A stable client who is 2 days post vaginal delivery of a term infant 2. A client presenting to the emergency department with signs/symptoms of a viral respiratory problem 3. An older adult client who is postoperative day 4 of a hip replacement 4. A client admitted to the ICU after a major myocardial infarction

A client admitted to the ICU after a major myocardial infarction The client with an MI would require more frequent charting due to the unstable changes occurring after a major MI.

Charting by exception (CBE) means which of the following? a. All normal patient activities are documented. b. Standardized terminologies are used. c. Abnormal patient responses are highlighted. d. Routine patient care is considered "normal."

Abnormal patient responses are highlighted. Charting by exception (CBE) is documentation that records only abnormal or significant data. It reduces charting time by assuming certain norms. For this type of charting, each facility must define what is normal. Any assessment finding outside normal is charted as an exception.

Identify examples that healthcare professionals may use in order to communicate specific information regarding the client or the client's care. (Select all that apply.) 1. Change-of-shift report 2. Discussing the client's care in the cafeteria 3. Contacting the physician via telephone regarding new orders for medication to decrease an increased temperature 4. Care plan conferences

Change-of-shift report Contacting the physician via telephone regarding new orders for medication to decrease an increased temperature Care plan conferences The client's status or care should never be discussed in situations where other persons may overhear the privileged information. Nurses have a legal and ethical duty to maintain confidentiality of the client's record, personal information, and any other information that relates to that individual's health care. Appropriate use of sharing client information includes during change-of-shift report, contacting the physician, and during care plan conferences.

The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take what actions to correct the error? Select all that apply. a. Document a late entry in the client's record. b. Draw 1 line through the error, initialing and dating it. c. Try to erase the error for space to write in the correct data. d. Use white out to delete the error to write in the correct data. e. Write a concise statement to explain why the correct was needed. f. Document the correct information and end with the nurse's signature and title

Document a late entry in the client's record. Document the correct information and end with the nurse's signature and title

After making a documentation error, which action should the nurse take? a. Use correcting liquid to cover the mistake and make a new entry. b. Draw a line through it and write error above the entry. c. Draw a line through it and write mistaken entry above it. d. Draw a line through the mistake and write mistaken entry with initials above it.

Draw a line through the mistake and write mistaken entry with initials above it. It is the most complete answer.

When the nurse places a check mark or a dash in an allocated space and uses an asterisk to reflect other pertinent information that has been recorded elsewhere on the chart, this is an example of what type of documentation? 1. Multi-disciplinary charting 2. Charting by exception 3. Focus charting 4. Flow sheet charting

Flow sheet charting Flow sheet charting allows nurses to record nursing data quickly and concisely. It provides an easy-to-read record of the client's condition over time.

The impact of computerized provider order entry (CPOE) on the medical record has been which of the following? a. Increased legibility of orders b. The need for more unit secretaries c. A reduction of duplicate orders d. Better billing practices.

Increased legibility of orders CPOE allows clinicians to enter orders in a computer that are sent directly to the appropriate department. Since unit secretaries are not needed for transcription, fewer may be needed. CPOEs may decrease duplicate orders but that is not the main benefit. Billing practices are not related.

The nurse notices a nursing staff member from another unit is reading the chart of one of the unit's patients. What action by the nurse is most appropriate? a. Don't worry since this staff member has a hospital ID badge. b. Tell the patient that someone from off the unit was reading the record. c. Ask the charge nurse if this person is allowed to read the record. d. Inform the staff person that he/she may not read records of patients not assigned to them.

Inform the staff person that he/she may not read records of patients not assigned to them. The confidentiality of patient information must be safe guarded and the information shared only with individuals who have a need and a right to know. Nurses have a professional and legal obligation to protect patient information. Since the nurse knows that the person is from another unit, the nurse must approach that person at that time.

The case management model using critical pathways would be appropriate for a client with which diagnosis? a. Myocardial infarction (heart attack) b. Diabetes, hypertension c. Myocardial infarction, diabetes, hypertension d. Diabetes, hypertension, an infected foot ulcer, senile dementia

Myocardial infarction (heart attack) Critical pathways work best for clients with one diagnosis

he physician orders: MSO4 2mg IV prn pain q 4-6 hours. Is this a good order? a. Yes b. No

No MSO4 is a do-not-use abbreviation

The registered nurse understands that which of the following is inappropriate to document? a. Nursing opinions of the patient's needs b. Accurate, timely, and relevant information c. All medications administered or withheld d. Nursing diagnoses and interventions

Nursing opinions of the patient's needs General principles of medical record documentation from the Centers for Medicare and Medicaid Services include the need for completeness and legibility; the reasons for each patient encounter, including assessments and diagnosis; and the plan of care, the patient's progress, and any changes in diagnosis and treatment. They do not require nursing opinions.

The nursing student learns that which of the following is the guideline for nursing documentation? a. HIPAA b. Code of Ethics c. Nursing process d. Ethical standards

Nursing process The ANA's model for high-quality nursing documentation reflects the nursing process. HIPAA, the Code of Ethics, and ethical standards do not provide the guideline for documentation.

The student nurse is learning to chart effectively in the clinical setting. Which action by the student nurse increases the student's knowledge about effective charting? 1. Chart and hope it is correct, 2. Practice charting and hope it will improve with time. 3. Do nothing now and learn charting after graduation. 4. Read charts to learn from actual situations

Read charts to learn from actual situations The student nurse needs to read the charts and ask questions such as "What are the diagnoses?" "What are they doing to treat the client?" "How is the client responding?"

A 74-year-old female is brought to the emergency department c/o right hip pain. The right leg is shorter than the left and is externally rotated.During inspection, the nurse observes what appears to be cigarette burns on the client's inner thighs. Which of the following is the most appropriate documentation? a. Six round skin lesions partially healed, on the inner thighs bilaterally b. Several burned areas on both of the client's inner thighs c. Multiple lesions on inner thighs possibly related to elder abuse d. Several lesions on inner thighs similar to cigarette burns

Six round skin lesions partially healed, on the inner thighs bilaterally This is the most specific, nonassuming, and nonjudgemental charting

In long-term care facilities, what two types of care are provided? (Select all that apply) 1. Easy 2. Skilled 3. Intermediate 4. Unskilled

Skilled and intermediate Skilled care clients require more extensive nursing with specialized nursing skills. The intermediate care focus is on clients with chronic illnesses.

The use of telephone and verbal orders has been reduced as a result of which of the following? a. More standing orders for patients in acute care environments b. The use of computerized order entry for the electronic health record c. The requirement for all orders to be in writing d. Staffing issues

The use of computerized order entry for the electronic health record The PCP can access the EMR from a smartphone, hand-held device, or personal computer and enter or send orders directly to the appropriate department.

The client has refused to have a Foley catheter inserted after surgery. What would need to be charted in the client's chart? 1. The client refused the Foley catheter. The client was educated about the need for the Foley and the consequences of refusing the treatment; client verbalized understanding of the education. 2. The client stubbornly refused the Foley catheter insertion. 3. The client was medicated and the Foley was inserted without difficulty. 4. The client refused the Foley catheter

The client refused the Foley catheter. The client was educated about the need for the Foley and the consequences of refusing the treatment; client verbalized understanding of the education. The documentation is complete and states that education was given informing the client of the consequences of refusal.

Which identifies accurate nursing documentation notations? Select all that apply. a. The client slept through the night. b. Abdominal wound dressing is dry and intact without drainage. c. The client seemed angry when awakened for vital sign measurement. d. The client appears to become anxious when it is time for respiratory treatments. e. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema

The client slept through the night. Abdominal wound dressing is dry and intact without drainage. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema

Which example of documentation is most correct when charting a client's behavior? 1. The client was shouting, "I am so mad that I am going to hit you if you come any closer." 2. The client seems angry and moderately aggressive. 3. The client is angry and shouting 4. The client stated that he was mad and wanted to hit someone.

The client was shouting, "I am so mad that I am going to hit you if you come any closer." The charting is specific, concise, descriptive, nonjudgmental, and objective. The other three examples are vague and subjective.

Legal issues related to medical records include which of the following? (Select all that apply.) a. The medical record is the legal documentation of care provided to a patient. b. In the event of litigation, the medical record is often the only available evidence. c. Medical record documentation should be based strictly on facts, not opinions. d. Medical record entries can be altered or erased to increase accuracy. e. The nurse cannot make corrections at all to the record.

The medical record is the legal documentation of care provided to a patient. In the event of litigation, the medical record is often the only available evidence. Medical record documentation should be based strictly on facts, not opinions. The medical record is the legal documentation of care provided to a patient. In the event of litigation, the medical record is often the only available evidence of the event in question. Medical record documentation should be based on fact, not opinions. Every note in a medical record must include a date, time, and signature with credentials. Ethical practice dictates that nurses document only interventions that are performed. Medical record entries cannot be altered or obliterated. However, there are specific policies for making a correction in the medical record.

Identify the purposes of charting. (Select all that apply.) 1. To fill up the nurse's spare time. 2. To communicate care and responses to care. 3. To create a legal document. 4. To demonstrate what the nurse did every moment of the shift. 5. To provide a basis for evaluation

To communicate care and responses to care. To create a legal document. To provide a basis for evaluation The main purposes of charting are to communicate care, help identify patterns of responses and changes in status, provide a basis for evaluation, provide a legal document, and supply validation for insurance purposes. The purpose of charting is not to fill up the nurse's spare time or to demonstrate what the nurse did every moment of the shift.

Which action by a nurse ensures confidentiality of a client's computer record? a. The nurse logs on to the client's file and leaves the computer to answer the client's call light. b. The nurse shares her computer password. c. The nurse closes a client's computer file and logs off. d. The nurse leaves client computer worksheets at the computer workstation.

The nurse closes a client's computer file and logs off. This action ensures client confidentiality

For a patient-related incident report, which of the following is correct? A. The report is included in the patient's record B. Only subjective information from the patient is included C. Possible causes of the incident are identified D. The nurse includes how the patient was found

The nurse includes how the patient was found Purpose of this report is to document the details of incident immediately to ensure accuracy

Which of the following is the best information to put in a flow sheet format? a. Admission note b. Diagnostic test results c. Provider's orders d. Vital sign measurements

Vital signs measurements Care and observations that are recorded on a basis, VS, medications, and intake and output measurements

It is the current belief that patient hand-offs can be improved with which of the following actions? a. Use of Standardized bedside shift reports b. Recorded messages left for oncoming staff c. Application of DAR recording d. Sharing written documents

Use of Standardized bedside shift reports For nurses to exchange information in the hand-off report to ensure that pertinent information was passed on to the next shift

If the nurse makes an error while charting, what is the recommended method to correct the mistake? 1. Use "correction fluid" and obliterate the error. 2. Draw one line through the error and write "'mistaken entry" above it, then sign your name or initials beside it. 3. Draw one line through the error and write "error" above it, then sign your initials beside it. 4. Do nothing and hope no one notices the error

Draw one line through the error and write "'mistaken entry" above it, then sign your name or initials beside it. Draw a line through it and write the words "mistaken entry" above or next to the original entry with your name or initials. Do not erase, blot out, correction fluid. Avoid writing the word "error" when recording that a mistake has been made.

The nurse is reviewing and order the physician has written using the abbreviation qid. Which of the following is the correct interpretation for this abbreviation? a. One time per day b. One time every other day c. Four times a day d. Three times a day

Four times a day

The nurse is checking the vital signs of the patient that she just received report on. Where would the nurse look to find this information? a. Client's progress notes b. Client's care summary c. Graphic record flow sheet d. The MARS

Graphic record flow sheet

The nurse finds a patient on the floor beside the bed. After doing an assessment and ensuring that the patient is safe and not injured, what action does the nurse take next? a. Complete an incident report. b. No further documentation is necessary. c. Ask your nursing assistant to report the incident. d. Call the risk manager.

Complete an incident report. When an unusual and unexpected event involving a patient, visitor, or staff member occurs, an incident report is completed. An incident may be the occurrence of a fall, a medication error, or an equipment malfunction. The purpose of this report is to document the details of the incident immediately to ensure accuracy. The incident must be documented whether or not the patient was injured. The nursing assistant can't complete the report since he/she was not the person who found the patient on the floor. The risk manager does not need to be called; he/she will be included in the routing of the report.

A new graduate nurse learns that the facility controls access to electronic health records by which of the following? a. Assignment of individual passwords b. Job designation and duties c. Human Resources as part of employment d. Signed documents by the patient or family

Assignment of individual passwords Access to an EHR is controlled through assignment of individual passwords and verification codes that identify people who have the right to enter the record. Passwords should never be shared with anyone. Health care information systems have the ability to track who uses the system and which records are accessed. These organizational tools contribute to the protection of personal health information. Anyone who has a need to access the record will see all of it; access is the same for all jobs. Human Resources does not control computer security. The patient or family does not have to sign papers allowing individuals to access their records.

The nursing student asks the faculty member why the electronic health record (EHR) is so important. What response by the faculty member is best? a. EHRs cost less to create and store digitally than paper charts. b. Allows all hospital providers the ability to see the whole record. c. Creates opportunities for research studies and data collection. d. Helps eliminate duplicate diagnostic testing.

Helps eliminate duplicate diagnostic testing. The electronic health record (EHR) includes documentation over time from inpatient and outpatient sources. It is a longitudinal record of that patient's encounters with the health system. Laboratory data and other test results are available in inpatient and outpatient settings so that care decisions can be made. Adoption of an EHR system eventually produces major cost savings through gains in productivity and error reduction, which ultimately improves patient health status; however, they are costly to create. They allow both inpatient and outpatient providers to access the record. Research is certainly easier with computerized records, but paper charts have been used for data collection too.

What is used to organize client data, allowing quick access for health care professionals to review information regarding the client? 1. End-of-shift report 2. SOAPIER notes 3. Variance reports 4. Kardex

Kardex The Kardex is used to provide quick access to client information. It should be kept updated at all times.

The registered nurse knows that medical record documentation is important for which reasons? (Select all that apply.) a. Improves communication between providers. b. It is the record of care provided. c. The record becomes a legal document. d. It is where the nurse records thoughts about patient care. e. Use of the nursing process can be demonstrated.

Improves communication between providers. It is the record of care provided. The record becomes a legal document. Use of the nursing process can be demonstrated. The medical record is a document with comprehensive information about a patient's health care encounter, as well as demographic, administrative, and clinical data. The record serves as the major communication tool between staff members and as a single data access point for everyone involved in the patient's care. It demonstrates the use of the nursing process. It is a legal document that must meet guidelines for completeness, accuracy, timeliness, accessibility, and authenticity.

What measures can the nurse take to maintain confidentiality of client records? (Select all that apply.) 1. Personal passwords are not shared with anyone else. 2. Never leave the computer unattended after logging into the system. 3. Do not leave paperwork with the client's information in an unsecured location. 4. Discard all unneeded computer-generated worksheets in the trash can

Personal passwords are not shared with anyone else. Never leave the computer unattended after logging into the system. Do not leave paperwork with the client's information in an unsecured location. The nurse has a legal and ethical duty to maintain confidentiality of the client's record. Personal passwords should not be shared, the nurse should never leave the computer unattended, and paperwork should not be left unattended in an unsecured location. Client records should never be discarded into a trash can; they should be shredded or disposed of per the facility policies.

During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks that the client's blood pressure (BP) seems high. What is the next step? a. Ask the client about past blood pressure ranges. b. Review the graphic record on the client's record. c. Examine the medication record for antihypertensive medications. d. Review the progress notes included in the client's record.

Review the graphic record on the client's record. The graphic record provides the trend of the vital signs