CoursePoint Chapter 4: Documentation and Interprofessional Communication

A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

Repeating the measurement with a different sphygmomanometer and stethoscope

Which of the following data entries follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

A nurse is providing a verbal update to a client's primary care provider because of the client's worsening nausea. When using an SBAR format to provide a report, the nurse should complete the report with which statement?

"I think this client would benefit from an antiemetic."

Which of the following examples of documentation best exemplifies sound clinical documentation practices?

"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."

The nurse is admitting a client to a medical unit. The client is concerned that all of his private health information is on the computer and an error may occur. What is the most appropriate response of the nurse?

"The electronic medical record is one of the tools we use to keep you safe."

The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write

"bilateral lung sounds clear."

The nurse knows that computerized medical record systems are expensive and can be complicated, but understands that they can significantly increase client safety. Some things that an electronic medical record can do are as follows: (Select all that apply.)

-Allow for several health team members to view a single chart simultaneously -Ensure that all entries are legible -Enable the graphing of trends in vital signs and assessments -Provide off-site viewing so personnel can note changes in the client's condition

The nursing instructor is teaching about the importance of good communication and accuracy when documenting on the client chart. Some things that are high-risk errors in documentation are the following: (Check all that apply.)

-Falsifying Client Records -Failing to record changes in a client's condition -performing an inadequate admission assessment -charting in advance

What are the primary frameworks used in conducting a health assessment? Select all that apply.

-Head to Toe -Body Systems -Functional Systems

When documenting assessment information in the medical record, what does the nurse know that the assessment information must accurately reflect? Select all that apply.

-what the nurse heard -what the nurse palpated -what the nurse observed

Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

A nurse is interpreting and making inferences from the data. The nurse is involved in which phase of the nursing process?

analysis

Abnormal assessment findings are clearly outlined in which documentation format?

Charting by exception

While the nurse performs the initial assessment, the client states "This is my first hospitalization and I have had no previous surgeries." How would the nurse document this information?

Client denies prior hospitalizations and surgeries

A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?

Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.

After performing a comprehensive assessment on a new client, the nurse documents the following findings. Which documentation follows acceptable documentation guidelines?

Client states, "I don't want to eat or do anything."

A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?

Cued or checklist forms

A client is having frequent blood pressure and blood glucose measurements to regulate an insulin infusion. Which type of documentation should the nurse use for this data?

Flow sheet

A nurse is working on a unit for clients with neurological conditions. Which assessment form would the nurse most likely use to document assessment data?

Focused assessment form

There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many health care providers questioning the rationale for this change in practice. What potential advantage of EHRs should administrators cite?

Improved continuity of care

A researcher in a health care facility is conducting a study without IRB approval. The researcher knows that this information is limited to what?

Internal quality improvement

A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?

It allows several health team members to view the client record simultaneously.

When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason?

It becomes the foundation for the entire nursing process.

A computerized risk assessment report correlates data and provides scores on various aspects of clients in the health care facility. Why would this be beneficial for client care?

Notifies health care providers when clients show clinical signs of deterioration

The nurse documents data immediately after assessing the client. This is an example of:

Point-of-care documentation

A client with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the client's chart. The nurse knows to look at what part of the client's medical record to check the current medical diagnosis?

Progress notes

A client's pain has become increasingly severe, but the client has received the maximum doses of analgesics. The nurse is receiving a new analgesic order from the health care provider via telephone. How would the nurse best validate the new order?

Read the order back to the health care provider for confirmation.

The nurse has just completed taking the vital signs of a client and will need to validate the client's elevated temperature. Which method of validation will be the best for the nurse to use?

Recheck the client's temperature using another thermometer.

The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?

SBAR

Mistakes in charting can be costly to both the client and nurse. The Joint Commission has listed a primary cause for these mistakes as a failure in communication. Life-threatening errors in health care have been labeled as which of the following:

Sentinel Events

After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information as which of the following?

Subjective data and objective data

A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?

Use phrases instead of sentences to record data.

The nurse is providing care to a client who has had a significant change in their vital signs and worsening symptoms. How should the nurse communicate these new findings to the health care provider?

Use the SBAR model

A nurse is completing the intake assessment of an older adult who has just relocated to a long-term care facility. Which of the following nursing actions would be most important to ensure accurate data when gathering the resident's information?

Validating the data

A nurse is comparing the subjective data and objective data obtained from an assessment of a client who is thought to have hepatitis A. This nurse's comparison will achieve what benefit to this client's care?

Validation of Data

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

Verify the data by having another nurse come in to perform the percussion.

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations?

When communicating a client's change in condition to the client's physician.

The nurse uses the SBAR model when reporting on clients at the change of shift. This type of report incorporates what part of the nursing process?

assessment

Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse?

charting by exemption

A client is recovering from a total hip replacement. The plan of care for this client is based on previous standards and uses a multidisciplinary approach. The nurse is aware that this plan of care is also known as which of the following?

clinical pathway

During an accrediting agency visit, it is found that some client care standards are not being met. Where should problem solving occur in this instance?

facility level

A client on the medical-surgical floor begins to have shortness of breath along with a drop in blood pressure. The nurse understands the importance of time sequencing. When charting information on this client, the nurse should include the following: (Select all that apply.)

-Sequence of events -Time of interventions -Time the provider was notified

A group of nursing students are reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes?

It provides a chronologic source of client assessment data.

A group of nursing students is reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes?

It provides a chronologic source of client assessment data.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?

It provides quick access to abnormal findings.