Jensen Ch. 4: Documentation and Interprofessional Communication

A nursing student is working a 7 a.m. to 3 p.m. shift with a preceptor and is caring for three clients independently. When the preceptor asks if the student has completed charting all her assessments, the student informs the preceptor that she is going to do batch charting. The preceptor informs the student of which of the following about batch charting?

It contributes to many potential errors.

A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?

Ask the other nurse to read back what first nurse reported

The nurse thinks that a client with pitting edema would benefit from wearing antiembolism stockings. Which part of the SBAR communication model is the nurse completing?

Recommendation

A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use?

An assessment flow chart

During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?

"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."

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

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

The nurse prepares to document information collected during an assessment. Which statement correctly documents subjective data?

"I have pain across my entire forehead."

A client asks to see his medical record (chart). How would the nurse respond?

"I will get your chart and provide you with privacy to read it.'

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?

"Patient complaining of abdominal pain rated 8/10."

A nurse is documenting the intensity of a client's pain. What would be the most accurate entry?

"Patient states pain is a 9 on a scale of 1 to 10."

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

"bilateral lung sounds clear."

The nurse does a complete assessment on her client at the start of the 7 a.m. to 3 p.m. shift. When she enters the assessment data on the medical record, it should be preceded by which of the following to mark the time?

03/02/05 0700

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

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

A nurse is using a cardiovascular assessment documentation form. The nurse understands that this is an example of which type of form?

A focused area assessment form

A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation?

A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight

A nurse is working in a health care facility that is using charting by exception. Which of the following would the nurse expect to document?

Aching, burning pain in lower back

A nurse is in the elevator at the hospital. The nurse overhears another nurse laughing and making jokes about a client. Why is this situation a breach of confidentiality?

All client information is private and confidential

The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?

Assessment data in the medical record

The nurse receives the following report. A client was admitted for a left hip fracture following a fall at home. The client was diagnosed with osteoarthritis 7 years ago. The left leg is shorter than right. Ecchymosis noted over left hip and groin areas. Pedal pulses palpable and strong bilaterally. Patient reports a pain rating of 8. An orthopedic case management consult is needed. Which aspect of SBAR does the diagnosis of osteoarthritis 7 years ago represent?

Background

The nurse assesses all assigned clients and sits in the nursing station to document assessment data for all clients. This is an example of:

Batch charting

Abnormal assessment findings are clearly outlined in which documentation format?

Charting by exception

A nurse has just finished taking a client's vital signs and is comparing the results with those from his previous visit 3 months ago. Which of the following situations would require the nurse to validate the data?

Client's weight was 200 lb (91 kg) 3 months ago but 125 lb (57 kg) today.

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

Clinical pathway

A nurse assesses a pregnant client in her second trimester. The nurse documents the weight of the client and notices that the client has gained six (6) pounds over a week. How should the nurse validate if the weight taken is correct?

Compare if subjective findings support the data

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?

Cross out the incorrect statement with a single line.

A nurse has completed assessing a client and now must validate the collected data. What are the steps that the nurse should follow? Select all that apply.

Decide whether the data require validation. Determine ways to validate the data. Identify areas where data are missing.

A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document?

Decreased range of motion in right shoulder

A legal nurse consultant explains to a group of nursing students that the medial record serves what purpose? Select all that apply.

Determining eligibility for reimbursement Legal document of care A method to gather research data Promoting effective communication between caregivers

Which strategy reduces documentation errors? Select all that apply.

Document client information immediately. Designate a person to document during emergencies. Organize client data logically, using a timed sequence.

A nurse makes an incorrect entry onto a client's paper record during documentation of the assessment data. What is the correct way for the nurse to fix this error?

Draw a line through the error, write "error", and initial the entry

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

Falsifying client records Failing to record changes in a client's condition Performing an inadequate admission assessment Charting in advance

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?

Focused

A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data?

Focused assessment form

On reviewing a client's database following a physical examination, a nurse realizes that the client's weight has been steadily increasing over her past three visits. What follow-up question would be best for the nurse to pose to the client based on this finding?

Has your diet or exercise changed significantly in the past year?

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

Have the right to copy their health records.

The nurse is reviewing the client's medical record. Which does the nurse recognize as accurate documentation?

Hyperactive bowel sounds are heard in all four quadrants.

A client is being discharged from the hospital after a below-the-knee amputation. The nurse has completed the discharge and gives a copy of the discharge summary with client teaching and medications to the client. The nurse understands the importance of doing a good assessment prior to discharge for which of the following purposes:

Identify necessary resources and strategies for successful home management.

Examples of objective data include all the following except:

Itchy skin

A nurse is conscientious in adhering to the requirements of the Health Insurance Portability and Accountability Act (HIPAA) when providing care for clients. What action best meets these legal requirements for care?

Maintaining the privacy and confidentiality of clients' medical records

Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?

Meaningful use of electronic health records

The Health Insurance Portability and Accountability Act mandates client confidentiality. What methods of protecting client confidentiality are included?

Never sharing computer passwords

A health care agency has been asked to compensate a client as per a lawsuit filed against it for not following the Health Insurance Portability and Accountability Act (HIPAA) regulations. Which of the following situations is a HIPAA violation?

Not informing a client in writing of the purpose of sharing his or her personal details.

What is the name of the information program mandated by the federal government for the initial and ongoing assessment of Medicare and Medicaid clients in the homecare setting?

OASIS

When performing an assessment, which of the following would be most helpful in validating a client's chief complaint?

Objective data

The nurse responds to a call light for a client rating their pain "ten out of ten." The nurse's initial inspection reveals the client is watching videos and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain?

Perform further assessments addressing various aspects of the client's pain.

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

Progress notes

A 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?

Progress notes

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

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

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?

Reassess blood pressure

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

Repeating the measurement with a different sphygmomanometer and stethoscope

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

SBAR

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?

SOAP charting

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

Sequence of events Time of interventions Time the provider was notified

A nurse has completed an assessment of a client with cholecystitis and is about to document the findings. Which statement best reflects accurate documentation?

Skin pale, warm, and dry without evidence of lesions.

A nurse is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect? Select all that apply.

The client's occupation The client's family history of cancer The client's weight-lifting routine

A nurse is having a new client complete a health history form and sign a form acknowledging his rights under the Health Insurance Portability and Accountability Act (HIPAA). The client asks the nurse what HIPAA covers. Which of the following most accurately describes what HIPAA covers?

The confidentiality of electronic and printed health information

A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?

The laboratory assistant can only retrieve medical records but cannot view the details.

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

Use phrases instead of sentences to record data.

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

Validating the data

The nurse is preparing to leave the unit for lunch. What type of communication method should the nurse use?

Verbal handoff

A client who had a mastectomy is being discharged home on postoperative day 1. Knowing that the client lives alone, which data would be most important for the nurse to validate for this client?

What support systems are in place to assist the client

A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply):

accurate organized complete timely concise

A nurse is caring for a client who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called:

charting by exception

In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed

focused

The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form

prevents missed questions during data collection.

What information concerning a client's respirations should the nurse record after completing a general physical assessment?

rate, rhythm, and depth of respirations taken for a full minute

Why is accurate and effective documentation most important?

Documentation constitutes a legal record.

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

Analysis

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

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

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?

Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10

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

It becomes the foundation for the entire nursing process.

What statement about batch charting is most accurate?

It contributes to many potential errors.

After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?

To communicate effectively with other health care team members

A nurse who is new to the health clinic and who recently graduated from a nursing program tells a client at the end of an interview that data the nurse has just collected from the client needs to be validated. The client, an elderly gentleman, gives the nurse a strange look and says, "Validate my data? What does that mean?" How should the nurse respond to this client?

"It means I need to make sure that all the information I gathered today is reliable and accurate."

A nursing instructor is teaching a student about the importance of documenting all interventions on the client record for reimbursement purposes. The instructor knows the student understands when she states which of the following:

"Lack of appropriate charting can affect whether financial payment will be authorized."

The nurse manager reviews documentation completed by a graduate nurse. Which entry should the manager question? Select all that apply

Appetite good Right foot swollen Vital signs normal

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?

Evidence in a situation of wrongdoing

The nurse prepares information to provide to the nurse scheduled to work the next shift. Which type of communication is the nurse preparing?

Handoff report

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

Improved continuity of care

A hospital is revising the policies and procedures surrounding documentation in an effort to align practices with the Health Information Technology for Economic and Clinical Health (HITECH) Act. How can the requirements of this legislation best be met?

Increase the use of electronic health records (EHRs) in the hospital.

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

Internal quality improvement

The nurse manager is implementing walking client rounds for the change-of-shift reports. One benefit of this type of reporting over others is:

It facilitates active participation of clients.

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

It provides a chronologic source of client assessment data.

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

It provides quick access to abnormal findings.

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

Notifies health care providers when clients show clinical signs of deterioration

The nurse is reviewing the client's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the client's status?

Progress notes

A client is being discharged home. The discharge note that the nurse writes for this client provides information for what purpose?

Resources and strategies for managing the client at home

A novice nurse is preparing for a physical examination of a client with neurological issues. The nurse takes a copy of the practice's standard assessment form and heads to the examination room, where the client is already waiting. A senior nurse notes the novice nurse's actions and says, "Here, use this form instead; it's an assessment form specifically for the neurological system." This second form is an example of which type of form?

Specialty area assessment form

The nurse is reviewing a SOAPIE note in the client's medical record. The nurse recognizes that "States no longer nauseous and would like something to eat" is which part of the SOAP note.

Subjective

A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following?

Subjective data and objective data

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

Subjective data and objective data

Which of the following should be included in the documentation of subjective data in the nurse's findings from the physical examination of the head and neck in the client with acute neck pain?

The client reports worsening pain in the neck when she looks down.

The nurse is reviewing and analyzing data from the initial assessment of a newly admitted client who is a 79-year-old man. What assessment finding most clearly indicates a need for further data?

The man has a diffuse rash on his torso.

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

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

The nursing instructor is teaching a class on documentation in the medical record. What would be the most important piece of information the instructor would give to the students?

The problem, intervention, evaluation(PIE) system of documentation does not use assessment as part of the PIE note

The nurse is caring for a client with a terminal illness. What would be the purpose of convening a family care conference?

To coordinate all aspects of the client's care

The nursing instructor is demonstrating to the student how to perform a physical assessment on a client. The instructor stresses the importance of being precise when doing an assessment. Another necessary aspect of the assessment to render safe and effective care is which of the following:

accurate documentation

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

assessment

Nurses are aware that "handoff" can significantly increase the risk for errors. Common examples of "handoffs" are as follows (check all that apply):

at change of shift when a nurse leaves for lunch when a client is transferred from the PACU to the floor

If the nurse makes an error while documenting findings on a client's record, the nurse should

draw a line through the error, writing "error" and initialing.