Chapter 19 Documenting and Reporting

PIE documentation

- Groups information into three categories: Problem, Interventions, Evaluation - Consists of a client assessment flow sheet and progress notes

Which is true of collaborative pathways?

Are also called critical pathways or care maps

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions

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

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

A new graduate is working at a first job. Which statement is most important for the new nurse to follow?

Use abbreviations approved by the facility.

Problem oriented documentation

organized around patient problems, allows collaboration, but required cooperation

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation

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 is able to log in and enter the information so all members of the health care team can see it."

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?

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

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?

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

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 The nurse should use SBAR (situation, background, assessment, recommendation) when communicating with the health care provider. SOAP and PIE are nursing notes in the medical record, and MAR is medication administration record.

Source oriented documentation

each discipline records findings separately - easy to find info, but data is scattered