Documentation Questions

What is the essential difference between PIE and SOAPE formats?

PIE is from nursing model; soape is medical

What information is tracked on flow sheets? (Select all that apply).A) Physicians nameB) Vital signsC) Lab resultsD) Hygiene (I/O measurements in graphs and flow charts)E) Ambulation activityF) Discharge PlanG) Restraint checks

B, D, E, G

What does Focus charting DAR include? (Select all that apply).A) DemographicsB) DataC) Alertness SummaryD) ActionE) ReferralsF) Response

B, D, F

A system used to consolidate patient orders and care needs in a centralized, concise way.

Kardex

Which of the following are examples of events that would be recorded by an incident or occurrence report? (Select all that apply).A) Patient fallB) MRI machine not workingC) Needle stickD) Medication errorE) Ambulance arrival in the ER

A,C,D

Define Client record:A) A confidential, permanent legal documentation of information relevant to a client's health care.B) Name, address, phone number, insurance information.C) List of medications.D) Temporary notes made pertaining to the clients current visit made on the nurses pocket notepad.

A

Define reports:A) Oral, written, or audiotaped exchanges between caregivers.B) Summary of xrays, MRI and Sonograms done on patient.C) Documentation of all activity patient has had previously for current condition.D) Review of all patients for cause trending.

A

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 necessary for health care providers to write orders."C) "Health care providers can write orders from any computer that has Internet access."D) "CPOE reduces the time nurses use to communicate with health care providers."

A

Match the correct entry with the appropriate SOAP category. 1=S 2=O 3=A 4=P A: Repositioned pt on right side. Encouraged pt to use patient-controlled analgesia deviceB: "the pain increases every time I try to turn on my left side"C: Acute pain related to tissue injury from surgical incisionD: left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation

1=B 2=D 3=C 4=A S=subjective O=objective A=assessment P=plan

SOAP--medical records based includes what type of information?A) SubjectiveB) OrganizedC) ObjectiveD) AnalyticalE) AssessmentF) Plan

A, C, E, F Subjective Objective Assessment Plan

Describe what Critical Pathways are.A) Multidisciplinary care plans that include client problems, key interventions, and expected outcomes. Involves all of health care team for a particular patient.B) Emergency Room proticolC) Critical Care Crash TeamD) Steps to take when patient is critical and not expected to survive.

A

Documentation is:A) Anything written or printed that you rely on as record or proof for authorized persons.B) Lab results for a patient you are taking care of.C) Admission paperwork for billing purposes.D) Instructions from the attending doctor.

A

What does being "Complete" mean?A) Documentation containing appropriate and essential informationB) A list of patients food likes and dislikes.C) A full narrative of how the patient was cared for.

A

What is Auditing?A) Objective, ongoing review of records to determine the degree to which quality improvement standards are met.B) Investigation by TJC for fraudC) Employee performance evaluationsD) Research on "Never Events".

A

What is a Kardex?A) Has activity, treatment, nursing care plan sections that organize information for quick reference. Older method, not used so much any more.B) A medication for the lips.C) Roledex of contact information for Physicians and other healthcare professionals.D) Charts kept at the end of the patients bed that provides all of their medical information.

A

You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.)A) The patient's name, age, and admitting diagnosisB) Allergies to food and medicationsC) Your evaluation that the patient is "needy"D) How much the patient ate for breakfastE) That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol

A, B, E

What information should be included in a transfer report? (Select all that apply)A) Client's nameB) AgeC) Marital StatusD) EmployerE) Primary physicianF) Medical diagnosisG) Summary of progressH) Current health statusI) InsuranceJ) AllergiesK) Need for additional equipment

A, B, E, F, G, H, J, K

PIE--nursing based charting. (Select all that apply).A) ProblemB) AssessmentC) InterventionD) EvaluationE) Expectations

A, C, D

List major areas to include in a change of shift report. (Select all that apply).A) Date & Time.B) Census countC) Essential background information.D) Client's nursing diagnosis or health care problems and their related causes.E) Length of time you have cared for patient.F) Description of objective measurements or observations G) Significant information about family members.H) Discharge plan.I) List of patients belongings.J) Significant changes in the way therapies are to be given.K) Any patient education completed.L) Evaluation of nursing care to dateM) Priorities

A, C, D, F, G, H, J, K, L, M

Select all that apply: A. Allows staff to develop standardized integrated care plans for a projected length of stay for patients of a specific case type. B. Clinical pathways that delve with cases occur in high volume and are predictable. C. The clinical pathway replaces other nursing forms such as the nursing care plans D. Charting by exception is usually the method used for clinical pathways E. The exact contents and format of these clinical pathways are the same among different institutions.

A-D

Which of the following are considered examples of record keeping forms? Select all that apply. A.Kardex or Rand B. Nursing Care Plan C. Incident Reports D. 24-hour patient care and acuity charting E. Discharge summary

A-E

Which of the following are considered the principal sections of a problem-oriented medical record? Select all that apply. A. Database B. Problem list C. Care plan D. Physical examination and diagnostic tests E. Referral form

ABCD

Which of the following statements regarding the DARE format of documentation are correct? Select all that apply A. Data, action, response and evaluation, education and patient teaching B. Data is both subjective and objective C. Action combines planning and implementation D. You need to use all the DARE steps each time you make notes on a particular focus E. Response is the same as evaluation and effectiveness F. Some facilities include education or patient teaching

ABCEF

Which of the following statements about home health care are true? Select all that apply A. It provides a narrower scope of people for a wider majority of services. B. Requires a whole health care team to work closely C. Does not demand meticulous and thorough documentation D. Duplication of documentation is difficult to avoid

ABD

Which of the following is a typical section of a traditional chart? Select all that apply A. Admission sheet and physician's orders B. Progress notes and nurse's admission information C. History and Physical Examination Data D. Medical Administration Record E. Care plan and nurse's notes

ABDE

What kind of notes are taken when charting by exception? Select all that apply. A. Additional treatments done or planned treatments withheld B. Standing orders and physical history C. New Concerns D. Changes in patient condition

ACD

There are facilities that require narrative notes for each shift to include a minimum of at least three entries. Legally, care is not given if care is not charted. This is true but it is time consuming and requires excessive detail and a defensive manner in doing so. To solve this issue, what did some hospitals come up with? CBE Which of the following formats is included under Charting be exception? Select all that apply. A. PIE B. SOAPE C. SOAPIER D. APIE

AD

List the information that needs to be documented with telephone reports. (Select all that apply).A) Date & TIme of callB) DiagnosisC) Physicans nameD) Who was calledE) Why they were called (info they were given and info that was received from them)

ADE

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

ANS: A Ideally, discharge planning begins at admission. Right before discharge is too late for discharge planning. After the congestion is treated is also too late for discharge planning. Usually the primary care provider writes the order too close to discharge, and nurses do not need an order to begin the teaching that will be needed for discharge. By identifying discharge needs early, nursing and other health care professionals can begin planning for home care, support services, and any equipment needs at home

Identify the purposes of a health care record. (Select all that apply.)a. Communicationb. Legal documentation c. Reimbursement d. Educatione. Researchf. Nursing process

ANS: A, B, C, D, EThe patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing (reimbursement), education, research, and auditing/monitoring. Nursing process is a way of thinking and performing nursing care; it is not a purpose of a health care record.

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 ox 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.

ANS: AAccurate documentation of supplies and equipment used assists in accurate and timely reimbursement. Your documentation clarifies the type of treatment a patient receives and supports reimbursement to the health care agency. None of the other options had equipment orsupplies listed. Avoid using generalized, empty phrases such as "status unchanged" or "had a good day." Do not enter personal opinions—stating that the patient is cooperative is a personal opinion and should be avoided. "Finally, patient had no complaints" is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care

Explain what "Current" means.A) The direction the patient is laying when they are on a bed.B) Timely entries; immediate documentation of information as it is collected from the client.C) Patient's ability to tell you the date and time.D) Patient's health history as it relates to their recent issues.

B

A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart. What is the preceptor's best response?a. "A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care."b. "A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs."c. "A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities."d. "A change-of-shift report provides important information to caregivers and develops relationships within the health care team."

ANS: AProperly performed, a hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care. Reimbursement costs and research priorities/opportunities are functions of the medical record. The purpose of the change-of-shiftreport is not to establish relationships but to ensure patient safety and continuity of care

A nurse is charting on a patient's record. Which action is most accurate legally?a. Charts legiblyb. States the patient is belligerentc. Uses correction fluid to correct errord. Writes entry for another nurse

ANS: ARecord all entries legibly. Do not write personal opinions. Enter only objective and factual observations of patient's behavior; quote all patient comments. For example, patient refuses to cough and deep breathe, saying, "I don't care what you say, I will not do it." Do not erase, apply correction fluid, or scratch out errors made while recording. Chart only for yourself

A nurse prepared an audiotaped exchange with another nurse of information about a patient.Which action did the nurse complete? The nurse completed aa. Report.b. Record.c. Consultation.d. Referral

ANS: AReports are oral, written, or audiotaped exchanges of information among caregivers. A patient's record or chart is a confidential, permanent legal document consisting of information relevant to his or her health care. Consultations are another form of discussion in which oneprofessional caregiver gives formal advice about the care of a patient to another caregiver. Nurses document referrals (arrangements for the services of another care provider).

Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients' health records?a. The nurse determines the degree to which standards of care are met by reviewing patients' health records.b. The nurse realizes that care not documented in patients' health records still qualifies as care provided.c. The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records.d. The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment.

ANS: AThe patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing/monitoring. The auditing/monitoring purpose involves nurses auditing records throughout the year to determine the degree to which standards of care are met and to identify areas needing improvement and staff development. The legal documentation purpose involves the concept that even though nursing care may have been excellent, in a court of law, "care not documented is care not provided." The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patient's recorded findings to determine whether the new method was more effective than the standard protocol. Analysis of data from research contributes to evidence-based nursing practice and quality health care

A preceptor is working with a new nurse on documentation. Which situation will cause thepreceptor to intervene?a. The new nurse uses a black ink pen to chart.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

ANS: B Chart consecutively, line by line (not every other line); if space is left, draw a line horizontally through it, and sign your name at the end. Every other line should not be left blank. Record all entries legibly and in black ink. End each entry with your signature and title. For computer documentation, keep your password to yourself. Using black ink, ending each entry with signature and title, and keeping the password secure are all appropriate behaviors

Which situation will require the nurse to obtain a telephone order?a. As the nurse and primary 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 primary 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 primary care provider in the patient's medical record.

ANS: BA registered nurse makes a telephone report when significant events or changes in a patient's condition have occurred. Telephone orders and verbal orders usually occur at night or during emergencies. Because the time is 1 AM (0100 military time) and the primary care provider isnot present, the nurse will need to call the primary care provider for a telephone order. A verbal order (VO) involves the health care provider giving orders to a nurse while they are standing near each other. Just reading an order that is correctly written in the chart does not require a telephone order

A nurse wants to integrate all pertinent patient information into one record, regardless of thenumber of times a patient enters the health care system. Which term should the nurse use todescribe this system?a. Electronic medical recordb. Electronic health recordc. Electronic charting recordd. Electronic problem record

ANS: BA unique feature of an electronic health record (EHR) is its ability to integrate all pertinent patient information into one record, regardless of the number of times a patient enters a health care system. Although the electronic medical record (EMR) contains patient data gathered in ahealth care setting at a specific time and place and is a part of the EHR, the two terms are frequently used interchangeably. There are no such terms as electronic charting record or electronic problem record

A nurse is discussing the advantages of standardized documentation forms in the nursinginformation system. Which advantage should the nurse describe?a. Varied clinical databasesb. Reduced errors of omissionc. Increased hospital costsd. More time to read charts

ANS: BAdvantages associated with the nursing information system include increased time to spend with patients (not more time to read charts); better access to information; enhanced quality of documentation; reduced errors of omission; reduced, not increased, hospital costs; increasednurse job satisfaction; compliance with requirements of accrediting agencies (e.g., TJC); and development of a common, not varied, clinical database

A patient is being discharged home. Which information should the nurse include?a. Acuity levelb. Community resourcesc. Standardized care pland. Kardex

ANS: BDischarge documentation includes medications, diet, community resources, follow-up care, and whom to contact in case of an emergency or for questions. A patient's acuity level, usually determined by a computer program, is based on the type and number of nursing interventions (e.g., intravenous [IV] therapy, wound care, ambulation assistance) required over a 24-hour period. Acuity level can be used for staffing and billing. Some institutions use standardized care plans to make documentation more efficient. The plans, based on theinstitution's standards of nursing practice, are preprinted, established guidelines used to care for patients who have similar health problems. In some settings, a Kardex, a portable "flip-over" file or notebook, is kept at the nurses' station. Most Kardex forms have an activity and treatment section and a nursing care plan section, which organize information for quick reference.

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

ANS: BNurses' documentation practices in home health, long-term care, and hospitals can determine reimbursement for health care. Sentinel events do not determine reimbursement. About 60% of the worst types of medical errors, called sentinel events (involving death or severephysical/psychological injury), relate to communication problems that often arise during telephone reports. A clinical information system (CIS) does not have to be installed by 2014 to obtain reimbursement. CIS programs include monitoring systems; order entry systems; andlaboratory, radiology, and pharmacy systems. Diagnosis-related groups (DRGs) are the basis for establishing reimbursement for patient care, not HIPAA. Legislation to protect patient privacy regarding health information is the Health Insurance Portability and Accountability Act (HIPAA).

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning and for meeting quality improvementwithin and across facilities. Which task did the nurse just complete?a. A focused assessment/specific body systemb. The Resident Assessment Instrument/Minimum Data Setc. An admission assessment and acuity leveld. An intake assessment form and auditing phase

ANS: BYou assess each resident in a long-term care agency receiving funding from Medicare and Medicaid programs using the Resident Assessment Instrument/Minimum Data Set (RAI/MDS). This documentation provides standardized protocols for assessment and care planning and a minimum data set to promote quality improvement within and across facilities. A focused assessment is limited to a specific body system. An admission assessment andacuity level is performed in the hospital. An intake assessment is for home health. There is no such thing as an auditing phase

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

ANS: C Use of exact measurements establishes accuracy. Charting that an abdominal wound is "5 cm in length without redness, drainage, or edema" is more descriptive than "large wound healing well." Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as "status unchanged" or "had a good day." It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions. "Patient is hard to care for" is a personal opinion and should be avoided. It is also a critical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, "Refuses all treatments and medications."

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

ANS: C, D, E, FWhen faxing, use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. An automatic sign-off is a safety mechanism that logs a user off the computer system after a specified period of inactivity. An automatic sign-off is used in mostpatient care areas and other departments that handle sensitive data. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information. All papers containing PHI (e.g., Social Security number, date of birth or age, patient's name or address) must be destroyed. Most agencies have shredders or locked receptacles for shredding and later incineration. Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. A firewall is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information and should not be bypassed.

A nurse has taught the patient how to use crutches. The patient went up and down the stairsusing crutches with no difficulties. Which information will the nurse use for the "I" in PIEcharting?a. Patient went up and down stairsb. Deficient knowledge regarding crutchesc. Demonstrated use of crutchesd. Used crutches with no difficulties

ANS: CA second progress note method is the PIE format. The narrative note includes P—Problem, I—Intervention, and E—Evaluation. The intervention is "Demonstrated use of crutches." "Patient went up and down stairs" and "Used crutches with no difficulties" are examples of the E. "Deficient knowledge regarding crutches" is the P.

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. Focus charting using the DAR format.b. Add this data to the problem list.c. Document the variance in the patient's record.d. Report a positive variance in the next interdisciplinary team meeting.

ANS: CA variance occurs when the activities on the critical pathway are not completed as predicted, or the patient does not meet expected outcomes. An example of a variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a patient progresses more rapidly than expected (e.g., use of a Foley catheter may be discontinued a day early). When a nurse is using the problem-oriented medical record, after analyzing data, health care team members identify problems and make a single problem list. A type of narrative format charting is focus charting. It involves the use of DAR notes, which include D—Data (both subjective and objective), A—Action or nursing intervention, and R—Response of the patient (i.e., evaluation of effectiveness).

A nurse developed the following discharge summary sheet. Which critical information should be added? TOPIC DISCHARGESUMMARY MedicationDietActivity levelFollow-up careWound carePhone numbersWhen to call the doctorTime of dischargea. Kardex formb. Admission nursing historyc. Mode of transportationd. SOAP notes

ANS: CList actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. In some settings, a Kardex, a portable "flip-over" file or notebook, is kept at the nurses' station. A Kardex is for nurses, not for patients to take upon discharge. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style

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 systemb. Nursing process designc. Critical pathway designd. Computerized provider order entry system

ANS: COne design model for Nursing Information Systems (NIS) is the protocol or critical pathway design. With this design, all health care providers use a protocol system to document the care they provide. A clinical decision support system is based on "rules" and "if-then" statements, linking information and/or producing alerts, warnings, or other information for the user. Thenursing process design is the most traditional design for an NIS. This design organizes documentation within well-established formats such as admission and postoperativeassessments, problem lists, care plans, discharge planning instructions, and intervention lists or notes. Computerized provider order entry (CPOE) is a process by which the health care provider directly enters orders for patient care into the hospital information system.

A nurse obtained a telephone order from a primary care provider for a patient in pain. Whichchart entry should the nurse document?a. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.b. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN, read back.c. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.d. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN.

ANS: CThe nurse receiving a TO writes down the complete order or enters it into the computer as it is being given. Then he or she reads the order back to the health care provider, called read back, and receives confirmation from the person who gave the order that it is correct. An examplefollows: "10/16/2011: 0815, Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Knight/J. Woods, RN, read back." VO stands for verbal order, not telephone order. The doctor's name and read back must be included in the chart entry

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

ANS: CWhen you are a student in a clinical setting, confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares patient information with a friend, confidentiality and HIPAA standardshave been violated. You can review your patients' medical records only to seek information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patient's medical record and plan of care. You do notshare this information with classmates and you do not access the medical records of other patients on the unit

SOAPIE is the SOAP meathod with what two additional steps?A) Individual care planB) InterventionC) ExpectationsD) Evaluation

B, D

A nurse is preparing a change-of-shift report for a patient who had chest pain. Which information is critical for the nurse to include?a. Pupils equal and reactive to lightb. The family is a "pain"c. Had poor results from the pain medicationd. Sharp pain of 8 on a scale of 1 to 10

ANS: D Elements in a change-of-shift report include identification of significant changes in measurable terms (e.g., pain scale) and by observation. Report elements do not include normal findings or routine information retrievable from other sources or derogatory or inappropriate comments about the patient or family, which could possibly lead to legal charges if overheard by the patient or family. This kind of language contributes to prejudicial opinions about the patient. Don't simply describe results as "good" or "poor." Be specific.

A nurse is using the source record and wants to find the daily weights. Where should the nurselook?a. Databaseb. Medical history and examinationc. Progress notesd. Graphic sheet and flow sheet

ANS: D In a source record, the patient's chart has a separate section for each discipline (e.g., nursing, medicine, social work, respiratory therapy) in which to record data. Graphic sheets and flow sheets are records of repeated observations and measurements such as vital signs, daily weights, and intake and output. In the problem-oriented medical record, the database section contains all available assessment information pertaining to the patient (e.g., history and physical examination, the nurse's admission history and ongoing assessment, the dietitian's assessment, laboratory reports, radiologic test results). In the source record, the medical history and examination contain results of the initial examination performed by the physician, including findings, family history, confirmed diagnoses, and medical plan of care. In the source record, the progress notes contain an ongoing record of the patient's progress and response to medical therapy and a review of the disease process; it often is interdisciplinary and includes documentation from health-related disciplines (e.g., health care providers, physical therapy, social work).

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

ANS: D Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third party payers. An interprofessional plan of care is used rather than a nursing process form. A step-by-step skills manual and a list of possible procedures are not included in the record

Which behaviors indicate that the student nurse has a good understanding of confidentialityand 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 schoolb. Prints/copies material from the patient's health record for a graded care planc. Reviews assigned patient's record and another unassigned patient's recordd. Reads the progress notes of assigned patient's recorde. Gives a change-of-shift report to the oncoming nurse about the patientf. Discusses patient care with the hospital volunteer

ANS: D, EWhen you are a student in a clinical setting, confidentiality and compliance with HIPAA are part of professional practice. Reading the progress notes of an assigned patient's record and giving a change-of-shift report to the oncoming nurse about the patient are behaviors thatfollow HIPAA and confidentiality guidelines. Students and health care professionals may not discuss a patient's examination, observation, conversation, diagnosis, or treatment with other patients or staff not involved in the patient's care. To protect patient confidentiality, ensurethat written materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information), and never print material from an electronic health record for personal use.

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

ANS: DA factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. An objective description is the result of direct observation and measurement. For example, "B/P 80/50, patient diaphoretic, heart rate 102 and regular." Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the patient. Use of exact measurements establishes accuracy. For example, a description such as "Intake, 360 mL of water" is more accurate than "Patient drank an adequate amount of fluid."

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, RN0810 Notified primary care provider of patient's status. New orders received.-------------------Jane More, RN0815 Portable x-ray of L hip taken in room. States, "I feel fine."-------------------Jane More, RN0830 Incident report completed and placed on chart.-------------------Jane More, RNa. 0800b. 0810c. 0815d. 0830

ANS: DNote that you do not include mention of the incident report in the patient's medical record. Instead you document in the patient's medical record an objective description of what happened, what you observed, and follow-up actions taken. It is important to evaluate anddocument the patient's response to the error or incident. Always contact the patient's health care provider whenever an incident happens

A nurse wants to reduce data entry errors on the computer system. Which behavior should thenurse implement?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.

ANS: DTo increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patient's bedside to facilitate immediate documentation of information as it is collected from a patient. A good system requires frequent and randomchanges in personal passwords to prevent unauthorized persons from tampering with records. When using a health care agency computer system, it is essential that you do not share your computer password with anyone under any circumstances. You destroy (e.g., shred) anything that is printed when the information is no longer needed. Taking nursing notes home is a violation of the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality.

A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse:A) Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report.B) Gives a newly ordered medication before entering the order in the patient's medical record.C) Reads the orders back to the health care provider after receiving them and verifies their accuracy.D) Asks the preceptor to listen in on the phone conversation.

B

A patient asks for a copy of her medical record. The best response by the nurse is to:A) State that only her family may read the record.B) Indicate that she has the right to read her record.C) Tell her that she is not allowed to read her record.D) Explain that only health care workers have access to her record.

B

Define Referrals:A) A physicians order for lab workB) An arrangement for services by another care providerC) Any physicians order that requires a authorization from the insurance company.D) Treatment options the physician discusses with the patient.

B

During a change-of-shift report:A) Two or more nurses always visit all patients to review their plan of care.B) The nurse should identify nursing diagnoses and clarify patient priorities.C) Nurses should exchange judgments they have made about patient attitudes. D) Patient information is communcated from a nurse on a sending unit to a nurse on a receiving unit.

B

How is Charting by exception different than other charting methods?A) It focuses on only one diagnosis.B) Focuses on deviation from the established norm or abnormal findings, highlights trends or changes. If no new notes, then no new changes or findings. If nothing is there, it doesn't mean the nurse forgot it, it means there's nothing new.C) Charting done for patients who are in critical care and have multiple healthcare issues.

B

On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system?A) Information technology.B) Electronic health record.C) Personal health information.D) Administrative information system.

B

What are standardized care plans?A) Computer generated care plans based on patients age, weight, and height.B) Preprinted, set guidelines used to care for the client.C) Care plans dictated by TJC.D) Plans of care that work 100% of the time and require no deviation ever.

B

What does it meant to be accurate?A) Only having to check the vitals one time during a shift.B) The use of accepted abbreviations, symbols, and system of measures that are clear and easy to understandC) The weight of a patient in ounces.D) Spelling things correctly when writing notes.

B

Problem oriented medical record (POMR) includes what information?A) DemographicsB) DatabaseC) Pain levelD) Problem ListE) Care PlanF) Discharge PlanG) Progress notesH) Referrals

B, D, E, G

While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because:A) The nurses forgot to document on the pulmonary system.B) The nurses were charting by exception.C) The computer is not working correctly.D) The physician does not have authorization to view the nursing assessment.

B

You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet?A) The new federal laws require that teaching sheets be e-mailed to patients after they are discharged.B) You need to use words the patients can understand when writing the directions.C) The form needs to be given to patients in a sealed envelope to protect their health information.D) The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.

B

Explain the new rights for clients related to HIPPA.A) Patient right to leave healthcare facility.B) Patient education on privacy protections C) Patient's right to access their medical records.D) Provider must receive consent from patient before releasing information.E) Recourse options if privacy protections are violated.

B, C, D, E

What are the guidelines the nurse should follow when receiving a telephone order? (Select all that apply)A) Date & time of follow-up visitB) Clien'ts nameC) Room # (if applicable)D) Insurance informationE) DiagnosisF) Repeat & clarify orders with physicianG) Write TO or VO to indicat taken by phoneH) Date & Time order takenI) Physicians nameJ) Physician must sign order within timeframe required by institution (usually 24-48 hours).

B, C, E, F, G, H, I, J

Which of the following statements are true regarding basic rules for documentation. Select all that apply. A. Use direct quotes for objective assessments B. If a charting error is made, draw one line through the faulty information C. Chart only your own care even when someone else calls you for a late entry. D. Chart after care is provided, as soon as possible, and as often as needed E. Sign each block of charting with full legal initials and title

B,C,D

What are the guidelines for quality documentation and reporting? (Select all that apply)A) DetailedB) FactualC) OrganizedD) FocusedE) AccurateF) CompleteG) CurrentH) Electronically recorded

B,C,E,F,G

A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system?A) Electronic health recordB) Clinical documentationC) Clinical decision support systemD) Computerized physician order entry

C

Accreditation is:A) Certification by the ANA.B) Medicare approval.C) Joint Commission specifies guidelines for documentation.D) Passing the NCLEX.

C

An incident report is:A) A legal claim against a nurse for negligent nursing care.B) A summary report of all falls occurring on a nursing unit.C) A report of an event inconsistent with the routine care of a patient.D) A report of a nurse's behavior submitted to the hospital administration.

C

Case Management documenting is:A) Referral of patient to another provider.B) Interaction with Social Services to support patients needs away from healthcare facility.C) Incorporates a multidisciplinary approach to documenting care.D) Involvement of Qualtiy Assurance in the care of patients.

C

Define "Education".A) Nursing giving a patient a pamplet about various health conditions.B) Smoking cessation classesC) Learning the nature of an illness and the individual client's responsesD) Nursing care in local schools with school aged children.

C

Define consultations:A) Lab resultsB) End of shift transition to next shiftC) Form of discussion whereby one professional caregiver gives formal advice about the level of care of a client to another caregiver.D) Indication by billing on patients ability to pay.

C

If an error is made while recording, the nurse should: A: erase it or scratch it out B: leave a blank space in the note. C: Draw a single line through the error and initial it D: obtain a new nurse's note and rewrite the entries

C

What does it meant to be organized with documentation?A) Have everything in one folder so it can be found.B) Color code information from various departments to make it easier to identify that information.C) Communicate information in a logical order.D) Write legibily.

C

What does the admission nursing history form provide?A) Insurance B) DPOA informationC) Baseline data to compare with changes in the clients condition.D) Risk factors

C

What is an appropriate way for a nurse to dispose of printed patient information?A) Rip several times and place in a standard trash canB) Place in the patient's paper-based chartC) Place in a secure canister marked for shreddingD) Burn the documents

C

You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. 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 control over your personal health care information.D) HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

C

A nurse is giving a hand-off report to the oncoming nurse. Which information is critical for the nurse to report? a. The patient had a good day with no complaints. b. The family is demanding and argumentative. c. The patient has a new pain medication, Lortab. d. The family is poor and had to go on welfare

C Relay to staff significant changes in the way therapies are to be given (e.g., different position for pain relief, new medication). Don't simply describe results as "good" or "poor." Be specific. Don't use critical comments about patient's or family's behavior, such as "Mrs. Wills is so demanding." Don't engage in idle gossip.

There are facilities that require narrative notes for each shift to include a minimum of at least three entries. Legally, care is not given if care is not charted. This is true but it is time consuming and requires excessive detail and a defensive manner in doing so. To solve this issue, what did some hospitals come up with?

CBE

As you enter the patient's room, you notice that he is anxious to say something. He 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 documentation of the patient's emotional status?A) The patient has a defiant attitude and is demanding his test results.B) The patient appears to be upset with his nurse because he wants his test results immediately.C) The patient is demanding and complains frequently about his doctor.D) The patient stated that he felt frustrated by the lack of information he received regarding his tests.

D

Discharge summary forms tell you what?A) Diagnosis of patientB) Total charges of visitC) AllergiesD) Emphasize previous learning by the client and the care that should be continued.

D

Source record charting provides what?A) Reference information on where to find all resources.B) Key Code to help decifer physician notesC) Information of the source or cause of the patients illness.D) Separate section for each discipline

D

The primary purpose of a patient's medical record is to:A) Provide validation for hospital charges.B) Satisfy requirements of accreditation agencies.C) Provide the nurse with a defense against malpractice.D) Communication accurate, timely information about the patient.

D

The standards of documentation by the Joint Commission require:A) Narrative on how patient was cared for.B) Patient's vital signs every 4 hours.C) A resolution date for all planned outcomes.D) Documentation within the context of the nursing process, as well as evidence of client and family teaching and discharge planning.

D

What are Acuity records used for?A) Helps billing determine what to charge for a type of service.B) Sharpness; acuteness; keenness of patientC) The global standard for payment efficiencyD) Records that assist a nurse manager in planning staffing requirements for the future.

D

What does "Factual" mean?A) Giving the patients point of view to understand how they feel.B) Your opion of the patients condition or behavior.C) Emotional and psychological assessment of the patient.D) Descriptive, objective information about what a nurse sees, hears, feels, and smells.

D

Which of the following charting 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, 94 and regular following exercise.

D

Which of the following is correctly charted according to the six guidelines for quality recording?A: "Was depressed today"B:"respirations rapid; lung sounds clear"C:"Had a good day. Up and about in room."D:"Crying. States she does not want visitors to see her like this"

D: reason you need to document pt. exact words in quotations when recording subjective data.

What kind of documentation is the following? Pain scale 0/10, hand and leg strong to right, weak to left. Skin pink, warm and dry, turgor good, incision to Rt. anterior chest wall erythema or edema ...................Jane Night, LPN.

Narrative

In the SOAPE format, if ever there is a need for changes, where will the REVISIONS (R) be included?

REVISIONS are noted in the EVALUATION section

Preprinted guidelines used to care for patients with similar health problems.

nursing care plan

Developed by nurses for nurses, it is based on nursing diagnoses and nursing assessment. It also includes, goals, plans for care and specific actions for care implementation and evaluation

standardized nursing care plans