Chapter 20 - Documenting and Reporting

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? "It will allow for us to see the client and possibly increase client participation in care." "It will let me see everything that has been done and things that need to be done." "It makes our client feel like we care, especially if we start the day off with a clean room." "It will give me a better sense of what my workload will be today."

"It will allow for us to see the client and possibly increase client participation in care."

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." "The care plan is the only way for nurses to document what they do." "The care plan provides additional documentation about the work of the nurse." "The care plan shows the medical diagnosis for the client."

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

What does ISBARR stand for?

- Identity/Introduction - Situation - Background - Assessment - Recommendation - Read back of orders/response

What are eight behaviors of purposeful rounding?

- Use Opening Key Words (C-I-CARE) with PRESENCE - Accomplish scheduled tasks - Address four Ps - Address additional personal needs, questions - Conduct environmental assessment - Ask "Is there anything else I can do for you? I have time." - Tell the patient when you will be back - Document the round

What is problem-oriented records?

A medical record approach that provides a quick and structured acquisition of the patient's history.

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? An audit A sentinel event A variance A never event

A variance

What is focus charting?

Action and response are reported with a specific date and time, showing the sequence of decision making based on evaluating patient responses.

Which is a drawback to the type of documentation known as charting by exception? Issues related to high-quality care should a negligence claim arise Increased time required to document information Less interdisciplinary communication Interference with standardized assessments

Interference with standardized assessments

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? Calling the client information desk to find out the room number of the family member Finding the emergency medical technicians who transported the family members and inquiring about the injuries Asking the emergency department nurse for information on the family member Accessing the electronic health record of the family member to find out extent of injury

Calling the client information desk to find out the room number of the family member

Which note includes all elements of a SOAP note? Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

Which is a drawback to the type of documentation known as charting by exception? Interference with standardized assessments Less interdisciplinary communication Issues related to high-quality care should a negligence claim arise Increased time required to document information

Issues related to high-quality care should a negligence claim arise

Which method of documentation is unique in that it does not develop a separate care plan but instead incorporates the care plan into the progress notes? Source-oriented records Problem-oriented records PIE (problem, intervention, evaluation) Focus charting

PIE (problem, intervention, evaluation)

What is source-oriented records?

Records that are grouped together based on point of origin.

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 PIE MAR SOAP

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? FOCUS charting SOAP charting PIE charting narrative charting

SOAP charting

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information Releasing the client's entire health record when only portions of the information are needed Disclosing client health information for research purposes after obtaining permission from the client's health care provider Submitting a written notice to all clients identifying the uses and disclosures of their health information

Submitting a written notice to all clients identifying the uses and disclosures of their health information

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? identifying risks and ensuring future safety for clients gauging the nurse's professional performance over time protecting the nurse and the hospital from litigation following up the incident with other members of the care team

identifying risks and ensuring future safety for clients

Besides being an instrument of continuous client care, the client's health care record also serves as a(an): incident report. assessment tool. Kardex. legal document.

legal document.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: limiting abbreviations to those approved for use by the institution. using only abbreviations whose meaning is self-evident to an educated health professional. ensuring that abbreviations are understandable to clients who may seek access to their health records. using only those abbreviations that are defined in full at another location in the client's chart.

limiting abbreviations to those approved for use by the institution.

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? problem list data base plan of care progress notes

progress notes