Chapter 19 Documenting, Reporting, Conferring

Which of the following abbreviations is on the list of the Joint Commission do not use abbreviations? Select all that 29. apply. A) U (unit) B) QD (daily) C) NPO (nothing per os) D) mL (milliliters) E) > (greater than)

Ans: A, B, E Feedback: The words "unit", "daily", "greater than" and "less than" should be spelled out. NPO, mL, and mcg are acceptable abbreviations.

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred 2. method of documentation. This documentation method may have which of the following drawbacks? A) Vulnerability to legal liability since nurse's safe, routine care is not recorded B) Increased workload for nurses in order to complete necessary documentation C) Failure to identify and record client problems and associated interventions D) Significant differences in the charting between nurses due to lack of standardization

Ans: A Feedback: A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

A nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to 20. nursing? A) Data, information, knowledge B) Process, documentation, analysis C) Research, controls, variables D) Hypothesis, nursing, practice

Ans: A Feedback: According to the ANA Scope and Standards of Nursing Informatics Practice, nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support clients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology (ANA, 2001, p. vii).

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart 1. should be written as ... A) Avelox (moxifloxacin) 400 mg daily B) Avelox (moxifloxacin) 400 mg Q.D. C) Avelox (moxifloxacin) 400 mg qd D) Avelox (moxifloxacin) 400 mg OD

Ans: A Feedback: Among the JCAHO's list of "do not use" abbreviations are Q.D., qd, and OD when denoting a once-per-day drug administration. Because of the potential for misinterpretation and consequent drug errors, the JCAHO recommends writing "daily" in the order.

18. What is the primary purpose of an incident report? A) Means of identifying risks B) Basis for staff evaluation C) Basis for disciplinary action D) Format for audiotaped report

Ans: A Feedback: An incident report, also termed a variance or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a client, employee, or visitor. Incident reports should not be used for disciplinary action against staff members.

The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, 36. Read Back) during which of the following clinical situations? A) When communicating a client's change in condition to the client's physician B) When providing a change-of-shift report to a colleague C) When documenting the care that was provided to a client whose condition recently deteriorated D) When reporting to a client's family member or significant other

Ans: A Feedback: ISBARR communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members. ISBARR is considered a framework for communication rather than a format for documentation.

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to 3. promote this goal? A) Narrative notes B) SOAP notes C) Focus charting D) Charting by exception

Ans: A Feedback: One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

A nurse caring for a client who is being treated by three physicians uses the source-oriented format for documentation. 24. What are the benefits of using this format of documentation? A) Information is documented in separate forms by each health care personnel. B) It is a unified, cooperative approach for resolving the client's problems. C) It is organized at one location according to the client's health problems. D) It is compiled to facilitate communication among health care professionals.

Ans: A Feedback: Source-oriented documentation is a record organized according to the source of documented information. This type of record contains separate forms on which health care personnel make written entries about their own specific activities in relation to the client's care. The problem-oriented method of recording demonstrates a unified, cooperative approach to resolving the client's problems. Source-oriented records are organized at numerous locations; there is not one location for information. The problem-oriented record is compiled to facilitate communication among health care professionals.

A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client 9. confidentiality? A) Writing the client's name on the student care plan B) Providing the instructor with plans for care C) Discussing the medications with a unit nurse D) Providing information to the physician about laboratory data

Ans: A Feedback: Students using client records are bound professionally and ethically to keep in strict confidence all the information they learn from those records. The student may discuss care with the instructor, medications with a staff nurse, and laboratory data with the physician. The student should not use actual client names or other identifiers in written assignments or oral reports.

Which one of the following methods of documentation is organized around client diagnoses rather than around patient 12. information? A) Problem-oriented medical record (POMR) B) Source-oriented record C) PIE charting system D) focus charting

Ans: A Feedback: The POMR is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care.

A nurse organizes client data using the SOAP format. Which of the following would be recorded under "S" of this 13. acronym? A) Client complaints of pain B) Client history C) Client's chief complaint D) Client interventions

Ans: A Feedback: The SOAP format (subjective data, objective data, Assessment [the caregiver's judgment about the situation], plan) is used to organize data entries in the progress notes of the POMR. A client complaint of pain is subjective data (S).

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would 4. appear at the beginning of a charting entry? A) "Client complaining of abdominal pain rated at 8/10." B) "Client is guarding her abdomen and occasionally moaning." C) "Client has a history of recent abdominal pain. "D) "2 mg Dilaudid PO administered with good effect"

Ans: A Feedback: The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a complaint of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse 35. anticipates finding which of the following? A) The physician's assessment and treatment B) Results of laboratory and diagnostic studies C) Nursing documentation and plan of care D) Information from other members of the health care team

Ans: A Feedback: The medical history, physical examination, and progress notes record the findings of physicians as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment.

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with 34. the health care provider? A) ISBAR B) EMAR C) SOAP D) CBE

Ans: A Feedback: The nurse should use ISBAR to communicate verbally to the health care provider. Identify/Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) is the communication tool to provide critical client information to the health care provider. EMAR is Electronic Medication Administration Record, which documents medication administration. SOAP is Subjective, Objective, Assessment, and Plan, which is a progress note that relates to only one health problem. CBE is Charting by Exception and permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution.

Which of the following are examples of incidental disclosures of client health information that are permitted? Select all 30. that apply. A) A nurse working in a physician's office puts out a sign-in sheet for incoming clients. B) Two nurses are overheard talking about a client through the door of an empty client room. C) A nurse places a client chart in a holder on the examining room door with the name facing out. D) A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms. E) A nurse calls out the name of a client who is seated in the waiting room.

Ans: A, B, E Feedback: Permitted incidental disclosures of PHI include using sign-in sheets without the reason for visit; the possibility of a conversation being overheard if measures are taken to be private; placing a client chart on the door with the face pages facing inward; placing an x-ray on a light board as long as it is not unattended; calling the name of a waiting patient; and leaving appointment reminders on answering machines (provided only a minimal amount of information is given).

Which of the following are examples of breaches of client confidentiality? Select all that apply. A) A nurse discusses a client with a coworker in the elevator. B) A nurse shares her computer password with a relative of a client. C) A nurse checks the medical record of a client to see who should be called in an emergency. D) A nurse updates the employer of a client regarding the client's return to work. E) A nurse uses a computer to document a client's response to pain medication.

Ans: A,B,D Feedback: Nurses may use computers to document client data as long as they are not in a public area, and as long as the computer is shut down following the entries. A nurse can also check the medical record for a relative to call in case of an emergency. All the other examples are violations of client confidentiality.

11. In what type of documentation method would a nurse document narrative notes in a nursing section? A) Problem-oriented medical record B) Source-oriented record C) PIE charting system D) Focus charting

Ans: B Feedback: A source-oriented record is one in which each health care group keeps data on its own separate form (e.g., physicians, nurses, and laboratory). Progress notes written by nurses using this method are narrative notes.

Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is 14. brought against a nurse? A) Problem-oriented medical record B) Charting by exception C) PIE charting system D) Focus charting

Ans: B Feedback: Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes. A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing.

The nurse should also avoid generalizations such as "seems comfortable today." The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner. 8. Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry? A) Alice J, RN B) A. Jones, RN C) Alice Jones D) AJRN

Ans: B Feedback: Each entry is signed with the first initial, last name, and title. In this case, A. Jones, RN, is correct.

26. A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? A) Client assessment B) Intervention carried out C) Written plan of care D) Multidisciplinary interventions

Ans: B Feedback: In the PIE notes, the nurse documents the problem, intervention and evaluation. Thus the nurse would document the intervention carried out. Client assessment is not a part of the PIE notes, because this information is recorded on flow sheets for each shift. Although the PIE system uses a nursing plan-of-care format, there is no written plan of care. The PIE system is not multidisciplinary; it provides a documentation system for nursing only.

A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified 17. facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)? A) PIE system B) Minimum data set C) OASIS D) Charting by exception

Ans: B Feedback: Long-term care documentation is specified by the RAI with the minimum data set forming the foundation for the assessment. This is required in all facilities certified to participate in Medicare or Medicaid. OASIS is used in the home health care industry.

10. A physician's order reads "up ad lib." What does this mean in terms of client activity? A) May walk twice a day B) May be up as desired C) May only go to the bathroom D) Must remain on bed rest

Ans: B Feedback: The abbreviation "up ad lib" means the client may be up as desired.

A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care 21. of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse? A) "I am sorry that you had to suffer this way. The nurse on night duty should be fired." B) "It's hard to be in bed and ask for help. You ring for a nurse who never seems to help." C) "You seem to be impatient. The nurses work very hard and they do whatever they can." D) "I can see that you are angry. What the nurse did is wrong, and it won't happen again."

Ans: B Feedback: The nurse should empathize with the client to perceive how the client is feeling. The nurse shares his or her perception with the client, which makes him comfortable to share his anxieties, fear, and concerns. The first response conveys pity on the client, which is inappropriate. In the third response, the nurse is taking the side of the nursing staff and the client may not like it. The fourth response is nontherapeutic.

32. In which of the following cases should a progress note be written? Select all that apply. A) For any nurse-client interaction B) When admitting a client C) When receiving a client postoperatively D) When assisting a client with ADLs E) When a procedure is performed

Ans: B, C, E Feedback: A progress note should be written in the following instances: upon admission, transfer to another unit, and discharge; when a procedure is performed; upon receiving a client postoperatively or postprocedure; upon communicating with physicians regarding critical client information (e.g., abnormal lab value result); or for any change in client status.

A nurse in a nursing home is writing a note that addresses the care a resident has received during the day and the 28. resident's response to care. What type of note does this represent? A) PIE note B) Flow sheet C) Narrative note D) SOAP note

Ans: C Feedback: A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, client activity pattern, and comfort measures provided, along with the client's response.

15. A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next? A) Date it and put it in the client's record. B) Sign it and put it in the Kardex. C) Individualize it to the specific client. D) Use it as printed, based on common needs.

Ans: C Feedback: Standardized care plans that identify common problems and needs with relation to select client cohorts may be used. Unless such care plans are individualized to a specific client, however, they may not address individual client needs.

A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. 25. The nurse demonstrates understanding of this method by identifying which of the following as the first step? A) Plan of care B) Data, action, and response C) Problem selected D) Nursing activities during a shift

Ans: C Feedback: The SOAP method begins by selecting a problem from a list. PIE (problems, interventions, and evaluation) notes incorporate the plan of care into the progress notes. Focus DAR notes organizes entries by data, action, and response. The narrative notes are used to record relevant client and nursing activities throughout a shift.

5. What is the nurse's best defense if a client alleges nursing negligence? A) Testimony of other nurses B) Testimony of expert witnesses C) Client's record D) Client's family

Ans: C Feedback: The client record is the only permanent legal document that details the nurse's interactions with the client. It is the best defense if a client or client surrogate alleges nursing negligence.

7. Which of the following data entries follows the recommended guidelines for documenting data? A) "Client is overwhelmed by the diagnosis of pancreatic cancer." B) "Client's kidneys are producing sufficient amount of measured urine." C) "Following oxygen administration, vital signs returned to baseline." D) "Client complained about the quality of the nursing care provided on previous shift."

Ans: C Feedback: The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers.

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client 33. records. Which of the following would be most appropriate for the nurse to do? A) Completely erase or delete the erroneous entry if possible. B) Use a highlighter to mark the incorrect entry and place initials next to it. C) Strike out the entry with a single line, place initials next to it, and write the correct entry. D) Black out the erroneous entry with a dark pen or marker.

Ans: C Feedback: The nurse should strike out the erroneous entry with a single line and place initials over it. When an error occurs, erasure or use of correction fluid is not permissible. Use of highlighters is not allowed and can draw attention to the erroneous documentation.

27. What activity in charting will assist most in the avoidance of errors? A) Objectivity B) Organization C) Legibility D) Timeliness

Ans: D Feedback: Documentation in a timely manner can help avoid errors.

6. A nurse is documenting the intensity of a client's pain. What would be the most accurate entry? A) "Client complaining of severe pain." B) "Client appears to be in a lot of pain and is crying." C) "Client states has pain; walking in hall with ease." D) "Client states pain is a 9 on a scale of 1 to 10."

Ans: D Feedback: Information should be documented in a complete, accurate, relevant, and factual manner. Avoid interpretations of behavior, generalizations, and words such as "good."

19. A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called? A) Nursing care conferences B) Staff visits C) Interdisciplinary referrals D) Nursing care rounds

Ans: D Feedback: Nursing care rounds are procedures in which a group of nurses visits select clients individually at each client's bedside. The primary purposes are to gather information to help plan and evaluate nursing care and to provide the client with an opportunity to discuss care.

16. What part of the client's record is commonly used to document specific client variables, such as vital signs? A) Progress notes B) Nursing notes C) Critical paths D) Graphic record

Ans: D Feedback: The graphic record is a form used to document specific client variables such as vital signs, weight, intake and output, and bowel movements.

A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure 22. maximum efficiency of change-of-shift reports? A) Pay courtesy calls to staff members before attending the meeting. B) Wait for the physicians to arrive before exchanging notes. C) Avoid asking questions related to the medical record. D) Come prepared with material required to take notes.

Ans: D Feedback: The nurse should come prepared with material required to take notes during the change-of-shift reports. The nurse should not delay the meeting for change-of-shift report by paying courtesy calls to staff members before attending the meeting. Change-of-shift reports are not conducted in the presence of physicians, thus the nurse does not need to wait for the physicians to arrive before exchanging notes. The nurse should ask questions related to the medical record if any information is unclear.

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in 23. documentation? A) Erase the incorrect statement and write the correct one. B) Cross out the wrong statement in a way that is not readable. C) Use correction fluid to obliterate what has been written. D) Cross out the incorrect statement with a single line.

Ans: D Feedback: When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one, nor cross out the wrong statement in a way that makes the statement unreadable, nor use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.