Foundations -- Module 12: Documenting & Reporting
B
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
A -- 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.
A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client 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 labs
1. repeats the order verbatim 2. enters order into paper or electronic system 3. documents it as verbal/phone order 4. includes date, time, physician's name, and RN signature
What are the guidelines for taking a verbal or telephone order?
PIE: P - Problem I - intervention E- evaluation SOAP S: subjective O: objective A: assessment P: plan
What are types of problem-oriented medical record documentation?
Joint Commission
What has standards and principles of nursing documentation?
EMR -- one episode/encounter of care EHR -- longitudinal record of health
What is the difference between EMR and EHR?
ineffective communication
What is the main cause of a sentient event?
patient record
What is the nurse's best defense against nursing negligence?
C -- 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.
What is the nurse's best defense is a client alleges nursing negligence? a. testimony of other nurses b. testimony of expert witnesses c. client's record d. client's family
medical record
the legal documentation of care provided to a patient
patient record
the only permanent legal document that details the nurse's interactions with the patient
informatics
the use of computers to systematically resolve issues in nursing
narrative documentation
traditional documentation format that is time-consuming and lengthy
A -- 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 JCAH recommends writing "daily" in the order.
A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart 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
B, C
A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? Select all that apply. a. cover errors with correction fluid, and write in the correct information b. put the date and time on all entries c. document objective data, leaving out opinions d. use as many abbreviations as possible e. wait until the end of shift to document
A -- 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.
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? a. "Client complaining of abdominal pain rated 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"
D -- 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 at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change of shift report? 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
A -- 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 nurse caring for a client who is being treated by three physicians uses the source-oriented format for documentation. 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 complied to facilitate communication among health care professionals.
C -- 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 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
C -- 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.
A nurse in a nursing home is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent? a. PIE note b. flow sheet c. narrative note d. SOAP note
A, B, D
A nurse is discussing occurrences that requires completion of an incident report. Which of the following should the nurse include in the teaching? Select all that apply. a. medication error b. needlesticks c. conflict with provider and nursing staff d. omission of prescription e. missed specimen collection of a prescribed lab test
B -- 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 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
D -- Information should be documented in a complete, accurate, relevant, and factual manner. Avoid interpretations of behavior, generalizations, and words such as "good."
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 1-10."
D -- 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.
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 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
A, B
A nurse is preparing information for a change of shift report. Which of the following information should the nurse include in the report? Select all that apply. a. input and output for the shift b. bone scan scheduled for today c. BP from the previous day d. medication routine from MAR
C Unless there is significant change in intake and output, the oncoming nurse can read that information in the chart. Unless there is a significant change in BP since the previous day, the oncoming nurse can read that information in the chart. The bone scan is important because the nurse might have to accommodate leaving the unit.
A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? a. input and output for the shift b. blood pressure from the previous day c. bone scan scheduled for today d. medication routine from the medication administration record
A, B, C
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all that apply. a. Repeat the details of the prescription back to the provider. b. Have another nurse listen to the telephone prescription. c. Obtain the provider's signature on the prescription within 24 hours. d. Decline the verbal prescription because it is not an emergency situation. e. Tell the charge nurse that the provider has prescribed morphine by telephone.
B, C, D, E
A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? Select all that apply. a. A single electronic records password is provided for nurses on the same unit b. family members should provide a code prior to receiving client health information c. communication of client information can occur at the nurses' station d. a client can request a copy of their medical record e. a nurse can photocopy a client's medical record for transfer to another facility
A -- 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 nurse organizes client data using the SOAP method. Which of the following would be recorded under "S" of this acronym? a. client complaints of pain b. client history c. client's chief complaint d. client interventions
A -- 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 nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to nursing? a. data, information, knowledge b. process, documentation, analysis c. research, controls, variables d. hypothesis, nursing, practice
B -- Each entry is signed with the first initial, last name, and title. In this case, A. Jones, RN, is correct.
Alice Jones, an RN, 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
a date, time, and signature with credentials
Every note in a medical record must include:
B -- 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.
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
A -- 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 is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which of the following? a. the physician's assessment and treatment b. results of lab and diagnostic studies c. nursing documentation and plan of care d. information from other members of the health care team
A -- 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.
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 promote this goal? a. narrative notes b. SOAP notes c. focus charting d. charting by exception
A -- he 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.
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 the health care provider? a. ISBAR b. EMAR c. SOAP d. CBE
A -- 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 should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, 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
A -- 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.
The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred 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
D
What activity in charting will assist most in the avoidance of errors? a. objectivity b. organization c. legibility d. timeliness
advanced directives, informed consents, power of attorney, and organ donation
What are four types of documents that are still usually on paper?
1. Nursing Assessment 2. care plan 3. interventions 4. patient's outcomes or response to care 5. assessment of patient's ability to manage care
What are the 5 critical aspects of documentation?
right task right circumstance right person right communication right supervision
What are the 5 rights of delegation?
A -- 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.
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
D -- The graphic record is a form used to document specific client variables such as vital signs, weight, intake and output, and bowel movements.
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
A, B, E The words "unit", "daily", "greater than" and "less than" should be spelled out. NPO, mL, and mcg are acceptable abbreviations.
Which of the following abbreviations is on the list of the Joint Commission do not use abbreviations? Select all that apply. a. U (unit) b. QD (daily) c. NPO (nothing per os) d. mL (milliliters) e. > (greater than)
A, B, D 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.
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.
A, B, E 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 incidental disclosures of client health information that are permitted? Select all 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.
C -- 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. 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.
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."
B -- 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.
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? a. problem-oriented medical problem b. charting by exception c. PIE charting system d. focus charting
A -- 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.
Which one of the following methods of documentation is organized around client diagnoses rather than around patient information? a. problem-oriented medical record b. source-oriented record c. PIE charting system d. focus charting
twice a day
You are taking a patient's vital signs b.i.d. How often do you do this?
medication administration record (MAR)
a list of ordered medications, along with dosages and times of administration
Electronic Health Record (EHR)
a longitudinal record of health that includes the information from inpatient and outpatient episodes of health care from one or more care settings
ISBAR communication
a process for effective hand-off communication among health care professionals about a patient's condition
Electronic Medical Record (EMR)
a record of one episode of care, such as an inpatient stay or an outpatient appointment
point of care documentation
occurs when nurses document assessment information as they gather it, often using a portable computer
handoff reports
passing patient-specific information from one caregiver to another; can occur between providers or between shifts
sentinel event
an unexpected occurrence involving death or serious physical or psychological injury or the risk of injury
flow sheet
documentation format used to document routine care and observations that are recorded on a regular basis, such as vital signs, medications, and intake and output measurements
charting by exception (CBE)
documentation format which records only abnormal or significant data
