Chapter 19 documentation test 3

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate?

"The benefit of CBE is less time needed on computer charting."

Telephone/Telemedicine Reports

-Identify yourself and the patient, and state your relationship to the patient. -Report concisely and accurately the change in the patient's condition that is of concern and what has already been done in response to this condition. -Report the patient's current vital signs and clinical manifestations. -Have the patient's record at hand to make knowledgeable responses to any physician's inquiries. -Concisely record time and date of the call, what was communicated, and physician's response.

Which pieces of information should the nurse treat as confidential and not disclose? Select all that apply.

A client's Social Security number Information about a client's past health conditions A client's address

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 variance

A nurse documents hypertension in a woman who is 5 months pregnant and then writes a narrative describing the situation. This type of abnormal status can be seen immediately with narrative easily retrieved in what documentation format?

Charting by exception

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

Which is the primary purpose of client records?

Communication

Focus charting (DAR)

Data (subjective and objective), action (nursing intervention), response (evaluation)

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

A nurse is assisting during a medical emergency on the medical unit. Which action by the nurse when documenting entries in a client's health care record would be the most accurate?

Making entries in chronological order

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.

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

SOAPIER charting

One of the lengthier documentation formats that typically is used in progress notes and the nurse's notes. It includes subjective data, objective data, assessment data, a plan, an intervention, an evaluation, and, as needed, a revision.

•PIE charting

Problem, Intervention, Evaluation - system is unique in that it does not develop a separate plan of care. Instead the plan of care is incorporated into the progress notes in which problems are identified by number.

Purposes of the Patient Record

Reimbursement Communication Education Research Quality Process & Performance Improvement Diagnostic & Therapeutic orders Care Planning Historical Documentation Credentialing, regulation and legislation Decision Analysis Legal documentation

The nurse hears an unlicensed assitive personel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

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

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting

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?

SBAR

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?

SOAP charting

S in SBAR stands for

Situation you are calling about - What is happening

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation?

Source-oriented

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.

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.

Which information should the nurse include in a client's plan of care? Select all that apply.

The client's problems, goals, and nursing orders Routine care, such as the client's bath and mouth care The client's level of activity and current medical orders

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

The lower extremities

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

What information should the nurse document in the medication record when administering a non-narcotic pain medication? Select all that apply.

Time Dose Reason given Effectiveness of medication

Which is not a purpose of the client care record?

To serve as a contract with the client

Which documentation by the nurse best supports the PIE charting system?

Vomiting 250 mL undigested food, antiemetic given, no further vomiting

Narrative charting

a descriptive record of client data and nursing interventions, written in sentences and paragraphs

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

a flow sheet

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.

any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders

SOAP charting

documentation style more likely to be used in a problem-oriented record

Source-oriented records

each health care group keeps data on its own separate form

HIPAA legislation includes punishments

for anyone caught violating patient privacy. Those who do so for financial gain can be fined as much as $250,000 or go to jail for as long as 10 years. Even accidentally breaking the rules can result in penalties, and embarrassment for you and your organization.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data.

ISBARR

introduction, situation, background, assessment, recommendation, read back

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?

progress notes

•SOAP

subjective, objective, assessment, plan

SOAPIER

subjective, objective, assessment, plan, intervention, evaluation, response.

Charting by exception

use of predetermined standards and norms to record only significant assessment data

The nurse receives a verbal order from a physician during an emergency situation. Which actions should be taken by the nurse? Select all that apply.

Read back the order. Mark the date and time of the order. Include V.O. with the physician name on the order.

B in SBAR stands for

background (•Pertinent information related situation) -admitting diagnosis -date of admission -important clinical information

Nurses are responsible for protecting records from

all unauthorized readers.

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them.

"I don't feel well. I've been urinating often, and it burns when I urinate." Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. Fever, possible urinary tract infection Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development?

"The care plan is required for every client by The Joint Commission."

A in SBAR stands for

Assessment Most recent v/s, oxygen, labs, if r/t situation

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."

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edmatous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"?

FOCUS

Nurses are legally and ethically obligated to keep all patient information confidential. give examples

Name, address, phone, fax, social security number, reason the person is sick, treatments, past health conditions

Guidelines for Change of Shift Report

•Follow a particular order and be concise •Provide basic identifying information •For new clients provide the reason for admission or medical diagnosis/es, surgery, diagnostic tests and therapies in the past 24 hours, client's support people •Significant changes in client's condition •Report client's need for emotional support •Abnormal occurrences during your shift •Report on clients who have been transferred or discharged •Clearly state priorities of care and care due after the shift begins - including any unfilled orders that need to be continued onto the next shift. •Describe any instructions given to patient/family & the response

What are Breaches in Patient Confidentiality

•Displaying information on a public screen •Sending confidential e-mail messages via public networks •Sharing printers among units with differing functions •Discarding copies of patient information in trash cans •Holding conversations that can be overheard •Faxing confidential information to unauthorized persons •Sending confidential messages overheard on pagers

SBAR

consistent, clear, structured, and easy-to-use method of communication between health care personnel; it organizes communication by the categories of: Situation, Background, Assessment, and Recommendations.

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

"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 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?

Problem-oriented method

R in SBAR stands for

Recommendation -your recommendation for resolving the problem -what you need from the healthcare provider

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation?

charting by exception

HIPAA requires that disclosure or requests regarding health information be limited to the

minimum necessary.

A nurse is giving the change-of-shift report on a client who has just returned from surgery. What client information should the nurse include in the report? Select all that apply.

name of the client intake and output prior to surgery client discharge teaching needs current vital signs

Strategies for safe computer charting

•Keep your password protected •Don't leave your computer unattended after you have logged in. •Know how to correct an error •Never create, change or delete records unless you have specific permission •Don't leave information about a patient displayed on a monitor where other may see it •Never use email to send protected health information unless it is encrypted •Follow facility policies for document sensitive diagnoses such as AIDS, HIV

Patients have the right to:

•See and copy their health record •Update their health record •Get a list of disclosures •Request a restriction on certain uses or disclosures •Choose how to receive health information

Methods of Documentation

•Source-oriented records & Narrative charting •Problem-oriented medication records •SOAP - subjective, objective, assessment, plan •SOAPIE - subjective, objective, assessment, plan, intervention, evaluation •SOAPIER - subjective, objective, assessment, plan, intervention, evaluation, response. •PIE charting (problem, intervention, evaluation) •Focus charting (DAR) - data, action, response •Charting by exception

INCIDENT OR OCCURRENCE REPORTS

•Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient •Do not document that an incident report was filed in the patient's chart. If it is mentioned then it can be pulled in for legal review.

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.

Guidelines for Quality Documentation

•Complete •Accurate •Concise •Factual •Organized & timely •Legally prudent •Confidential •Consistent with professional & agency standards