Chapter 16: Documenting, Reporting, Conferring, and Using Informatics

A student nurse asks why completing an acuity report is important. What is the best response by the nurse?

"It helps determine our staffing requirements."

A patient 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?

Accurately documenting patient care on the patient record

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. What action by the nurse is most appropriate?

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

Besides using the medical records, which form of communication should the nurse use to provide client details to the health care team coming on duty in the next shift?

Change of shift reports

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal handoff report?

Current client assessment

A nurse takes a patient's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?

Graphic sheets

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?

It provides quick access to abnormal findings.

What organization audits charts regularly?

Joint Commission on Accreditation of Healthcare Organizations

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?

Progress notes

When documenting information in a client's medical record, which of the following should the nurse do consistently for each entry?

Sign each entry by name and title.

A client has been diagnosed with PVD. What area of the body should the nurse focus the assessment?

The lower extremities

When the nurse recognizes that he has documented one client's assessment data on the wrong client's medical record, the nurse should

draw a single line through the error, initial it, and write the correct entry.

HIPAA allows incidental disclosures of patient health information as long as it cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of PHI. What are examples of this type of PHI disclosure?

• A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. • The nurse uses X-ray light boards that can be seen by passersby; however, patient x-rays are not left unattended on them. • The nurse calls out names in the waiting room, but does not disclose the reason for the patient visit.

A nurse recognizes an error in documentation regarding the site of a wound. What actions by the nurse are appropriate? (Select all that apply.)

• Put a single line through the incorrect entry. • Write the words "mistaken entry" above the incorrect entry.