Fundamentals of Nursing Ch 16 Documenting, Reporting, Conferring, and Using Informatics

The lower extremities

A client has been diagnosed with PVD. What area of the body should the nurse focus the assessment?

retrieval of information is more efficient

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic client chart is:

Use abbreviations approved by the facility.

A new graduate is working at her first job. Which statement is most important for the new nurse to follow?

Rates pain 8/10, states nauseated for last 30 minutes.

A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse best reflects the effectiveness of the pain medication?

Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth

A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines?

"The Joint Commission requires nursing care to be permanently integrated into the client record."

A student nurse asks a nurse why nurses cannot document in a separate record instead of the client record in order to document and find the information needed. What is the best response by the nurse?

Documentation

According to the American Nurses Association (ANA), what is the primary source of evidence to measure performance outcomes against standards of care?

have the right to copy their health records.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, patients:

Explain the reason why information cannot be disclosed.

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. What response by the nurse is most appropriate?

legal document.

Besides being an instrument of continuous client care, the client's medical record also serves as a(an):

Change of shift reports

Besides using the medical records, which form of communication should the nurse use to provide client details to the health care team coming on duty in the next shift?

It provides quick access to abnormal findings.

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

• Readable • Thoughtful • Timely, contemporaneous, and sequential • Clear, concise, and complete

The American Nurses Association (ANA) identifies effective documentation using which of the characteristics? (Select all that apply.)

"Myocardial infarction."

The doctor tells the client, "You are experiencing a MI," and leaves the room. The client asks the nurse what a MI stands for. What response by the nurse is most accurate?

Assess the triggers from the data.

The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. What action by the nurse is most appropriate?

Incident report

The nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report?

2130

The nurse is documenting an assessment that was completed at 9:30 pm. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

• Read back the order. • Mark the date and time of the order. • Include V.O. with the physician name on the order. • Have the physician review and sign the order during the emergency.

The nurse receives a verbal order from a physician during an emergency situation. What actions should be taken by the nurse? (Select all that apply.)

Review the hospital's process for allowing clients to view their medical records.

The nursing is caring for a client who requests to see a copy of his or her medical records. What action by the nurse is most appropriate?

Involving social services in client care to obtain needed prescriptions

What action by the nurse best demonstrates a consultation?

communication

What is the primary purpose of the patient record?

Sign each entry by name and title.

When documenting information in a client's medical record, which of the following should the nurse do consistently for each entry?

Limiting abbreviations to those approved for use by the institution.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

Nutritional consult

Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing?

Informatics

An area of specialization in nursing that is a combination of computer science, information science, and nursing science is termed

Read the client's history and assessment.

How can a nurse obtain additional information about a client?

• After introductions, the nurse states the patient name, room number, and problem. • The nurse states that the patient's condition "could be life-threatening." • The nurse reads back the physician's new orders at the conclusion of the call.

The nurse is using the ISBARR format to report a surgical patient's deteriorating condition to a physician. Which actions would the nurse perform when using this guide? (Select all that apply.)

"The main purpose of an incident report is for quality improvement, not disciplinary action."

The nurse manager overhears a nurse say, "I'm not going to fill out an incident report because it will be used against me." What response by the nurse manager is most appropriate?

The Joint Commission

Which organization audits charts regularly?

"A coronary artery bypass graft will benefit your heart."

A client is scheduled for a CABG procedure. What information should the nurse provide to the client?

1 Unit of glucose

A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information?

Communication is the primary purpose of client records

A nursing student is preparing a presentation on client records and documentation. What information should the student include in the presentation?

• A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. • The nurse uses X-ray light boards that can be seen by passersby; however, patient x-rays are not left unattended on them. • The nurse calls out names in the waiting room, but does not disclose the reason for the patient visit.

HIPAA allows incidental disclosures of patient health information as long as it cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of PHI. What are examples of this type of PHI disclosure? (Select all that apply.)

During a medical emergency

It is acceptable for the nurse to accept a verbal order from the physician in which of these situations?

draw a single line through the error, initial it, and write the correct entry

When the nurse recognizes that he has documented one client's assessment data on the wrong client's medical record, the nurse should

A graphic sheet

Which documentation tool will the nurse use to record the patient's vital signs every 4 hours?

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

Which example may illustrate a breach of confidentiality and security of client information?

Charting by exception

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest?

Graphic sheets

A nurse takes a patient's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?

• Quality improvement • Research • Decision Analysis • Financial reimbursement

A nurse is preparing a seminar on the uses of documentation in client records. Which topics should the nurse include in the seminar? (Select all that apply.)

It keeps the nurse close to the source of the data.

A physician suggests that the nurse use the computer terminal that is available at the point of care or at the client's bedside. What is the probable reason for the physician's suggestion?

Current client assessment

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal handoff report?

Progress notes

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?

Mr. Gray reports that on a scale of 1 to 10, the pain he is experiencing is a 3.

A nurse is documenting the effectiveness of a patient's pain management on the patient record. Which documentation is written correctly?

A referral

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for patients diagnosed with multiple sclerosis, and their families. Providing this information is an example of which of the following?

Inform the doctor you will need to get client permission to release any information.

A doctor approaches the nurse caring for the client in room 25 and states, "The client is a friend of mine. What treatment is being given?" What response by the nurse is most appropriate?

SOAP charting

A health care facility plans to evaluate and revise the plan of care for a client based on the client's medical records. The physician, dietitian, and the nurse involved in the client's care are required to collate all of the information for easy access. Which style do you think the agency is following in order to record the client details?

Charting by exception

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note, in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?

Problem-oriented method

A nurse documents the following patient data in the patient record according to the SOAP format: Patient complains of unrelieved pain; patient is seen clutching his side and grimacing; patient pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

Telemedicine and mobile technology

A nurse has a two-way video communication with the specialist involved in the care of a patient in a long-term care facility. This is an example of what nursing informatics technology?

"You can fill in information from your own records and store it on your computer or the Internet."

A nurse helps a patient who has cystic fibrosis prepare a standalone personal health record. Which statement by the nurse best explains this type of information?

A patient who is homebound and needs skilled nursing care

A nurse is arranging for home care for patients and reviews the Medicare reimbursement requirements. Which patient meets one of these requirements?

those directly involved in the client's care

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which people would be entitled to access of the client's records?

• The patient rates pain as 2 compared to a 7 yesterday. • Vital signs returned to normal. • Radial pulse 72, strong and regular

A nurse is documenting care for an elderly patient who is recovering from a mild stroke. Which documentation entries follow the recommended guidelines for communicating and documenting patient information? (Select all that apply.)

• The content is not in accordance with professional standards. • There are lines between the entries. • Dates and times of entries are omitted.

A nurse is documenting care for patients in a hospital setting. Which documenting errors may potentially increase the nurse's risk for legal problems? (Select all that apply.)

• Reporting the incidence of an infectious disease to Center for Disease Control • Releasing a medical record to the court when a nurse is being sued for negligence • Facilitating organ donation of a deceased patient • Providing statistics related to the use of a dangerous piece of equipment

A nurse manager of a physician's office is responsible for obtaining signed authorizations for releasing patient information to third parties. In which situations would the nurse not need an authorization from the patient? (Select all that apply.)

Identifying risks and ensuring future safety for clients

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation

Identifying risks and ensuring future safety for clients

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

The password and access number should be kept secret and changed regularly

A nurse uses the computer to access health records of the clients. What care should the nurse take when using a computer to access health records?

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

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

"Any information that can identify a person is considered a breach of client privacy."

A nursing instructor is discussing a nursing student's Facebook post about a very interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is most appropriate?

Discuss with the staff nurse that the recording of all client data, even when normal, is important in providing and evaluating care.

A nursing supervisor overhears one of the staff nurses say, "I only document vital signs when they are out of the normal range." What action by the nursing supervisor should be implemented first?

Accurately documenting patient care on the patient record

A patient accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?

The nurse meets with nurses or other health care professionals to discuss some aspect of patient care.

The nurse is finding it difficult to plan and implement care for a patient and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

Reporting

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Ask the client if information can be given to the parent

The parent of a 33 year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. What action by the nurse is most appropriate?

Ensure that the client's name appears on all pages.

When maintaining medical records for a client, the nurse knows that a medical record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?

SOAP charting

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing?

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

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

"If I make an error, I draw a single line through it and put my initials by it."

Which of the following statements by the student nurse demonstrates understanding of the appropriate way to document an error in her charting?

Precise measurements should be used rather than approximations.

Which principle should guide the nurse's documentation of entries on the client's medical record?