DOCUMENTATION Chapter 26 Potter and Perry

A nurse is completing an OASIS data set on a patient. The nurse works in which area? a.Home health b.Intensive care unit c.Skilled nursing facility d.Long-term care facility

A

After providing care, a nurse charts in the patient's record. Which entry will the nurse document? a.Appears restless when sitting in the chair b.Drank adequate amounts of water c.Apparently is asleep with eyes closed d.Skin pale and cool

D

A nurse is charting on a patient's record. Which action will the nurse take that is accurate legally? a.Charts legibly b.States the patient is belligerent c.Writes entry for another nurse d.Uses correction fluid to correct error

A

A nurse is using focused charting. Match the chart entry to the correct letter of the acronym. a.Applied oxygen, stayed with patient, and instructed to slow breathing. b.Patient states, "feel better," respirations 16 with O2 saturations 96%. c.Patient states, "can't catch my breath and chest hurts." Confused. 1.D 2.A 3.R

1. C 2. A 3. B

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A. "CPOE reduces transcription errors." B. "CPOE reduces the time needed for health care providers to write orders." C. "CPOE eliminates verbal and telephone orders from health care providers." D. "CPOE reduces the time nurses use to communicate with health care providers."

A

A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete? a.A verbal report b.An electronic record entry c.A referral d.An acuity rating

A

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing? a.A minimum data set b.An admission assessment and acuity level c.A focused assessment/specific body system d.An intake assessment form and auditing phase

A

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking? a.Determining the degree to which standards of care are met by reviewing patients' health records b.Realizing that care not documented in patients' health records still qualifies as care provided c.Basing reimbursement upon the diagnosis-related groups documented in patients' records d.Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment

A

A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session? a.Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care. b.A clinical information system must be installed by 2014 to obtain health care reimbursement. c.A "near miss" helps determine reimbursement issues for health care. d.HIPAA is the basis for establishing reimbursement for health care.

A

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient? a.Upon admission b.Right before discharge c.After the congestion is treated d.When the primary care provider writes the order

A

A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? a.Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. b.Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints. c.Breathing without difficulty. Sitting up in bed watching TV. Had a good day. d.Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.

A

The nurse is working the evening shift at a hospital that uses military time for documentation. The nurse administered morphine 2 mg intravenously (IV) for pain at 3:45 PM, changed the dressing over the patient's abdominal incision at 5:34 PM, and administered Ancef 1 g IV at 8:00 PM. Using correct military time, which of the following is the correct label of documentation for each task with the time that it was completed? A. 15 45, 17 34, 20 00 B. 3 45, 17 34, 20 00 C. 15 45, 5 34, 8 00 D. 3 45, 5 34, 8 00

A

A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.) a.Communication b.Legal documentation c.Reimbursement d.Nursing process e.Research f.Education

A, B, C, E, F

The nurse is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a registered nurse (RN) who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of information does the nurse include in the documentation of this telephone call? A. The patient's name, age, and admitting diagnoses B. The discussion of any allergies to food and medications that the patient has C. That the nurse receiving the report was advised that the patient is "needy" and "on the call light all the time" D. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol E. Description of any unresolved problems and current interventions in place

A, B, D, E

The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student: A. Documents a medication given by another nursing student. B. Includes the date and time of the entry into the medical record. C. Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient's room. D. Leaves a slip of paper with her user name and password in the patient's room. E. Starts to enter "Docusate sodium 100 mg ordered at 08:00 held. Patient declined to take dose stating, "I had several loose stools yesterday, and I'm afraid if I take this dose the problem will get worse," as a narrative comment.

A, D

A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting? a.Patient went up and down stairs b.Demonstrated use of crutches c.Used crutches with no difficulties d.Deficient knowledge related to never using crutches

B

A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe? a.Varied clinical databases b.Reduced errors of omission c.Increased hospital costs d.More time to read charts

B

A nurse is providing care to a group of patients. Which situation will require the nurse to obtain a telephone order? a.As the nurse and health care provider leave a patient's room, the primary care provider gives the nurse an order. b.At 0100, a patient's blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood. c.At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order. d.A nurse reads an order correctly as written by the health care provider in the patient's medical record.

B

A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse find? a.Electronic medical record b.Electronic health record c.Electronic charting record d.Electronic problem record

B

A patient is being discharged home. Which information should the nurse include? a.Acuity level b.Community resources c.Standardized care plan d.Signature for verbal order

B

A patient states, "I would like to see what is written in my medical record." What is the nurse's best response? A. "Only your family can read your medical record." B. "You have the right to read your record." C. "Patients are not allowed to read their records." D. "Only health care workers have access to patient records."

B

A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to follow up? a.The new nurse documents only for self. b.The new nurse charts consecutively on every other line. c.The new nurse ends each entry with signature and title. d.The new nurse keeps the password secure.

B

While reviewing the pulmonary assessment entered by a nurse in a patient's electronic medical record (EMR), a physician notices that the only information documented in that section is "WDL" (within defined limits). The physician also is not able to find a narrative description of the patient's respiratory status in the nurse's progress notes. What is the most likely reason for this? A. The nurse caring for the patient forgot to document on the pulmonary system. B. The EMR uses a charting-by-exception format. C. The computer shut down unexpectedly when the nurse was documenting the assessment. D. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment.

B

A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.) a.Bypass the firewall. b.Implement an automatic sign-off. c.Create a password with just letters. d.Use a programmed speed-dial key when faxing. e.Impose disciplinary actions for inappropriate access. f.Shred papers containing personal health information (PHI).

B, D, E, F

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using? a.Clinical decision support system b.Nursing process design c.Critical pathway design d.Computerized provider order entry system

C

A nurse developed the following discharge summary sheet. Which critical information should the nurse add? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge a.Clinical decision support system b.Admission nursing history c.Mode of transportation d.SOAP notes

C

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record? a.Status unchanged, doing well b.Patient seems to be in pain and states, "I feel uncomfortable." c.Left knee incision 1 inch in length without redness, drainage, or edema d.Patient is hard to care for and refuses all treatments and medications. Family is present.

C

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do? a.Add this data to the problem list. b.Focus chart using the DAR format. c.Document the variance in the patient's record. d.Report a positive variance in the next interdisciplinary team meeting.

C

A nurse is charting. Which information is critical for the nurse to document? a.The patient had a good day with no complaints. b.The family is demanding and argumentative. c.The patient received a pain medication, Lortab. d.The family is poor and had to go on welfare.

C

A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up? a.To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice. b.A nurse needs to know how to find, evaluate, and use information effectively. c.If a nurse has computer competency, the nurse is competent in informatics. d.Nursing informatics is a recognized specialty area of nursing practice.

C

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document? a.12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back. b.12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back. c.12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back. d.12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN.

C

A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? a.The student nurse reads the patient's plan of care. b.The student nurse reviews the patient's medical record. c.The student nurse shares patient information with a friend. d.The student nurse documents medication administered to the patient.

C

A preceptor observes a new graduate nurse discussing changes in a patient's condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse: A. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone. B. Documents the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record. C. Gives a newly ordered medication before entering the order in the patient's medical record. D. Asks the preceptor to listen in on the phone conversation.

C

The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system? A. Electronic health record B. Clinical documentation C. Clinical decision support system D. Computerized physician order entry

C

The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response? A. HIPAA allows all hospital staff access to your medical record. B. HIPAA limits the information that is documented in your medical record. C. HIPAA provides you with greater protection of your personal health information. D. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

C

What is the appropriate way for a nurse to dispose of information printed out from a patient's electronic health record? A. Rip the papers up into small pieces and place the pieces into a standard trash can B. Place all papers in the flip-top binder designated for that patient that is located in the nurse's station on the patient care unit C. Place papers with patient information in a secure canister marked for shredding D. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit

C

A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record? a.Nursing process form b.Step-by-step skills manual c.A list of possible procedures d.Reports to third-party payers

D

A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information? A. "Avoid rushing when documenting an entry in the medical record." B. "Use correction fluid to remove the entry." C. "Draw a single line through the statement and initial it." D. Enter only objective and factual information about a patient in the medical record.`

D

A nurse is preparing to document a patient who has chest pain. Which information is critical for the nurse to include? a.The family is a "pain." b.Pupils equal and reactive to light c.Had poor results from the pain medication d.Sharp pain of 8 on a scale of 1 to 10

D

A nurse wants to find the daily weights of a patient. Which form will the nurse use? a.Database b.Progress notes c.Patient care summary d.Graphic record and flow sheet

D

A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take? a.Use the same password all the time. b.Share password with only one other staff member. c.Print out and review computer nursing notes at home. d.Chart on the computer immediately after care is provided.

D

Which entry will require follow-up by the nurse manager? 0800 Patient states, "Fell out of bed." Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, "Did not pass out." Assisted back to bed. Call bell within reach. Bed monitor on. ——————-Jane More, RN 0810 Notified primary care provider of patient's status. New orders received. ——————-Jane More, RN 0815 Portable x-ray of L hip taken in room. States, "I feel fine." ——————-Jane More, RN 0830 Incident report completed and placed on chart. ——————-Jane More, RN a.0800 b.0810 c.0815 d.0830

D

Which of the following documentation entries is most accurate? A. "Patient walked up and down hallway with assistance, tolerated well." B. "Patient up, out of bed, walked down hallway and back to room, tolerated well." C. "Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk." D. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."

D

Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.) a.Writes the patient's room number and date of birth on a paper for school b.Prints/copies material from the patient's health record for a graded care plan c.Reviews assigned patient's record and another unassigned patient's record d.Gives a change-of-shift report to the oncoming nurse about the patient e.Reads the progress notes of assigned patient's record f.Discusses patient care with the hospital volunteer

D, E

As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this observation of the patient? A. "The patient has a defiant attitude and is demanding test results." B. "The patient appears to be upset with the nurse because he wants his test results immediately." C. The patient is demanding and is complaining about the doctor." D. "The patient stated feelings of frustration from the lack of information received regarding test results."

D.