Jensen's Health Assessment 3rd Ed. | Chapter 4

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?

To investigate the quality of care in the agency

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

Verbal handoff

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?

Vulnerability to legal liability since the nurse's safe, routine care is not recorded.

When documenting assessment information in the medical record, what does the nurse know that the assessment information must accurately reflect? Select all that apply.

What the nurse observed What the nurse palpated What the nurse heard

The nurse would perform handoff report for which situation? Select all that apply.

When leaving for lunch When sending the client for an endoscopy At shift change Upon transferring to ICU

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

A nurse is explaining to a new client that the office uses electronic health records (EHRs) for all clients. The client says that at his last office, they used electronic medical records (EMRs). He asks whether these are the same thing. The nurse explains that they are different. Which of the following is a characteristic that is true of an EMR?

A record supplied by a physician in which diagnoses and prescribed treatments are recorded

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

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

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?

Charting by exception

Why should the nurse document assessment findings?

Determine the educational needs of the client

The nurse completes documentation for a client. Which statement should be questioned?

Dressing on lower leg has some purulent drainage

During an accrediting agency visit, it is found that some client care standards are not being met. Where should problem solving occur in this instance?

Facility level

A client is having frequent blood pressure and blood glucose measurements to regulate an insulin infusion. Which type of documentation should the nurse use for this data?

Flow sheet

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

A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?

It allows several health team members to view the client record simultaneously.

A nurse charting the medical record for a client knows that which of the following forms of charting involves writing information about the client and client care in chronological order?

Narrative charting

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 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

The nurse is reviewing the patient'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 patient's status?

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

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

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 | Situation, Background, Assessment, Recommendation