Chapter 19: Documenting and Reporting

Which are appropriate actions for protecting clients' identities? Select all that apply. Ensure that clients' names on charts are visible to the public. Have conversations about clients in private places where they cannot be overheard. Place light boxes for examining X-rays with the client's name in private areas. Document all personnel who have accessed a client's record. Orient computer screens toward the public view.

Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.

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

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?

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

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

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation?

Attach a copy of the incident report to the chart.

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate? Mediate a meeting between the parent and client. Verify the insurance coverage before giving information. Refer the parent to the physician providing care. Explain the reason why information cannot be disclosed.

Explain the reason why information cannot be disclosed.

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 increase intestinal motility and prevent constipation." "A complete ablation of the biliary growth will decrease liver inflammation." "The CABG procedure will help identify nutritional needs."

"A coronary artery bypass graft will benefit your heart."

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate? "Be sure to put the client's name and room number on all paperwork." "Clipboards with client data should not leave the unit." "You can get an electronic printout of client lab data to take with you." "Be sure to write down specific information for your clinical paperwork."

"Clipboards with client data should not leave the unit."

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

"I will arrange access for you to review the record after you put your request in writing."

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.

A new graduate is working at a first job. Which statement is most important for the new nurse to follow? Only document changes in the client's status. Use abbreviations approved by the facility. Use PIE charting, even if it is not the institution's charting method. Document lengthy entries using complete sentences.

Use abbreviations approved by the facility.

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?"

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. current orders identifying demographics, including diagnosis what the client watched on television during the shift what time the nurse will return for the next shift any abnormal occurrences with the client during the shift

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

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? those directly involved in the client's care close friends of the client health care professionals of the facility any family member of the client

those directly involved in the client's care

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:

Although not written, the nurse must know or question the rationale before performing an action.

Which abbreviation is correct for use in documentation? BT Per os Sub q PO

PO

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest? narrative notes charting by exception problem, intervention, and evaluation note FOCUS data, action, and response note

charting by exception

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.