Chapter 19: Documenting and Reporting PrepU

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response? -"According to HIPAA legislation, you have a right to request changes to inaccurate information." -"HIPAA legislation allows for you to change any information." -"HIPAA legislation only allows access to review the medical record." -"According to HIPAA, medical records cannot be changed."

"According to HIPAA legislation, you have a right to request changes to inaccurate information." The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records. They may also update their health record if inaccurate, get a list of the disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations, request a restriction on certain uses or disclosures, and choose how to receive health information.

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? -"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." -"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." Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. Because the child is a minor, it is the parents' right to view the client's record. Therefore, the statements about the physician not giving the parents access to review the records and asking if the parents are questioning the care of their child are incorrect.

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given? -0930 -2130 -930 p.m. -1930

2130 Military time uses the 24-hour clock cycle. So, 9:30 p.m. is 2130 in military time.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? -Accessing the electronic health record of the family member to find out extent of injury -Asking the emergency department nurse for information on the family member -Finding the emergency medical technicians who transported the family members and inquiring about the injuries -Calling the client information desk to find out the room number of the family member

Calling the client information desk to find out the room number of the family member Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? -Recording nursing interventions -Omitting clients' responses to nursing interventions -Identifying nursing diagnoses or clients' needs -Documenting clients' health histories and discharge planning

Omitting clients' responses to nursing interventions Omitting clients' responses to nursing interventions is correct because it does not fit the criteria for legally defensible charting. Recording nursing interventions, identifying nursing diagnoses or client needs, and documenting clients' health histories and discharge planning are all criteria for legally defensible charting and would demonstrate evidence of quality care.

In SBAR, what does R stand for? -Reinforcing data -Report -Recommendations -Response

Recommendations SBAR stands for situation, background, assessment, and recommendations. The other responses are incorrect.

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? -data base -problem list -plan of care -progress notes

progress notes In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse? -"The hospital owns your records and does not have to allow you access while you are a client here." -"Let me open up the computer access so that you can see what information is of interest to you." -"I will have to review the policy that determines what procedure is in place for client access." -"You may not understand all of the information and it will confuse you so I will help you decipher it all."

"I will have to review the policy that determines what procedure is in place for client access." Clients have the right to see their own medical records and request changes to documentation that may be in error. Most facilities have a policy in place for the client to obtain medical records and the nurse should ensure that the policy is followed by being familiar with that policy prior to giving the client free access to the record. The nurse should not demean the client by assuming that the information may be confusing. The nurse should not allow the client access to the computer while using the nurse's password or login information. While the hospital maintains responsibility for the record, the client has the right to see it.

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in charting? -"If I make an error, I have to rewrite the entire entry." -"If I make an error, I draw a single line through it and put my initials by it." -"If I make an error, I use white-out on it." -"If I make an error, I can draw a red circle around it."

"If I make an error, I draw a single line through it and put my initials by it." When an error occurs, the nurse should draw a single line through the error and place his or her initials above it. If the nurse is using an EMR (electronic medical record), and the documentation cannot be changed - this will require an addendum.

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? -"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." -"The CABG procedure will help increase intestinal motility and prevent constipation."

"A coronary artery bypass graft will benefit your heart." Coronary artery bypass graft is abbreviated CABG. It does not identify nutritional needs, decrease liver inflammation, or increase intestinal motility.