Module 2: Components of Health Assessment

Healthcare providers who violate HIPAA may face fines of up to:

$250,000 or jail time

Which of the following actions are indicators for hand washing and hygiene? Select all that apply.

-After removing gloves. -When hands are visibly dirty or soiled. -Before eating and after using a restroom. -After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. -If moving from a contaminated body site to a clean body site during patient care.

focuses assessment

-Asks details related to current symptoms. Does not collect a review of systems. -Questions related to the current situation.

What are the purposes of the client health record? Select all that apply.

-Care planning -quality assurance -financial reimbursement -education -research -Legal document

Which of the following are considered high-risk errors in documentation? Select all that apply.

-Charting in advance -Performing an inadequate admission assessment -Failing to follow the agency's standards or policies on documentation

emergency assessment

-Collect only the most important information (reason for seeking care, current health problems medications, allergies). Defer obtaining details until client is stable. Assessment and intervention are concurrent. -Assessment and intervention are concurrent.

What are some advantages to using electronic medical records? Select all that apply.

-Ensures all entries are legible and time dated. -Significantly increases patient safety. -Allows healthcare providers to enter orders directly on their computer.

Which of the following are high risk errors in documentation that may lead to poor client outcomes or legal risk? Select all that apply.

-Failing to record changes in the client condition -Not following the agency's documentation policies -Performing an inadequate admission assessment -Charting in advance

tuning fork

-Gross assessment of hearing. -Used in two examinations of two anatomic regions: neuromuscular assessment and assessment of hearing.

Many barriers potentially contribute to difficulties in which of the following communications? Select all that apply.

-Hierarchy of relationships -Differences in ethnic background -Lack of standards and policies for communication

What are some of the disadvantages of the narrative documentation approach? Select all that apply.

-May include irrelevant information -time consuming

Common methods of recording assessments, interventions, and patient responses include which of the following? (Select all that apply).

-SOAP -PIE -DAR

The Health Insurance Portability and Accountability Act (HIPAA) regulates which of the following areas? Select all that apply.

-Security of records -Reimbursement -Coding -Information management

comprehensive assessment

-Thorough history and physical examination such as for a sports physical, or well visit. -Includes demographic data, a full description of the reason for seeking care, individual health history, family history, functional status, and a history in all physical and psychosocial areas.

What are some of the characteristics of an effective handoff strategy? Select all that apply.

-Use a standardized format -Communicate a face-to-face verbal update -Use written documentation to supplement the verbal handoff -Cross monitor handoffs of others

demographic data

-age -name -religious preference

COLDSPA acronym

-character -onset -location -duration -severity -pattern -associated factors/how it affects the patient

past health history

-childhood illness -surgeries -health screenings

What are some of the advantages of the narrative documentation approach? Select all that apply.

-easy to learn -easy to adjust length -can explain in detail

What are some of the advantages of using SOAP note documentation? Select all that apply.

-easy to track -Similar to steps in the nursing process -interdisciplinary

What are some of the disadvantages of using SOAP note documentation? Select all that apply.

-specific focus -lengthy and time consuming

secondary data source

-the family -the clients health record or chart

logical organization

A chronological record of assessments and nursing actions.

addominal-gastrointestinal

A history of colon cancer, cholelithiasis, liver failure, hepatitis, pancreatitis, colitis, or ulcers. Appetite, nausea, vomiting, and diarrhea.

eyes

A history of glaucoma and cataracts.

ears

A history of hearing loss and ear infections.

head and neck

A history of high or low thyroid hormone level. Syncope, dizziness, and sinus pain.

SOAP(IE)

Advantage: All charting focuses on identified or new problems. Disadvantage: Specific focus, makes charting general information difficult without identifying a problem.

DAR

Advantage: Broad view and works well in an ambulatory and long-term care. Disadvantage: Not multidisciplinary and may not relate to POC.

Narrative

Advantage: Easy to learn and can explain in detail. Disadvantage: Time consuming and may include irrelevant information.

Charting by exception

Advantage: Efficient and clearly outlines abnormal assessment. Disadvantage: Expensive to develop and educate staff regarding standards and may pose legal problems because details are often missing.

PIE

Advantage: Incorporates POC and less redundant. Disadvantage: May need to read progress note(s) to determine POC if not on separate document

sethoscope

Auscultating heart, lungs, abdomen.

working phase

Collect data by asking specific questions. Use open-ended questions to yield broad responses in the client's own words. Yes-no questions may be used when specific information is needed.

Pre-interaction phase

Collect data from the medical record, including the previous history of medical illnesses or surgeries, current medication list, and problem list.

background

Describe the circumstances leading up to the current situation.

accuracy

Descriptions are as precise as possible.

otoscope

Directs light into the ear to visualize the ear canal and tympanic membrane.

closing phase

End the interview by summarizing information and stating what the two to three most important patterns or problems might be.

patient care equipment

Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. Ensure the proper discarding of single-use items.

environmental control

Ensure that the facility has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces.

assessment

Give the objective and subjective data pertinent to the situation.

ophthalmoscope

Handheld system of lenses, lights, and mirrors enabling visualization of the interior structures of the eye.

linen

Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin exposure and contamination of clothing and that avoids transfer of microorganisms to other patients and environments.

Which of the following statements does not describe the process of inspection?

Is focused on the area of patient complaint.

confidential

Keeping information private

recommendation

Make suggestions for what needs to be done to manage the difficulty.

reflex hammer

Measurement of neurologic responses.

Lifespan Considerations

Parents, legal guardians, or other adult representatives serve as primary interview sources of health care information when patients are children.

timeliness

Prompt recording documented with accurate time.

An internal audit may be used for _______________ purposes.

Quality assurance

skin, hair, and nails

Rash, itching, pigmentation or texture change, lesions, sweating, and thick or yellow nails.

conciseness

Record findings, not how you collected them. Unnecessary elaboration may confuse important issues.

situation

State concisely why are you communicating.

beginning phase

The nurse introduces self by name and states the purpose of the interview, the follows with some neutral topics, possibly simply conversational, such as the weather.

human violence assessment

The nurse should routinely question patients about the possibility of physical abuse.

mental health assessment

The patient is anxious, depressed, or sounds illogical, or an association may exist between current physical status and psychiatric concerns.

Psychosocial and lifestyle factors

alcohol use

Which situational consideration is indicated by nail-biting, foot-tapping, sweating, and pacing?

anxiety

Cultural considerations include all except which of the following?

diet restrictions

A past health history includes all except:

dietary requirements

What term is used to describe how long a percussion tone lasts?

duration

Batch charting reduces the risk of potential errors.

false

Closed-ended or direct questions are broad and yield responses in the patient's own words.

false

SOAP note documentation is interdisciplinary, brief and quick, and hard to track.

false

The acronym POC means Point of Care.

false

You should encourage "why" questions to find out more information from the patient.

false

_____________ are especially important to nursing because they focus on the effects of health or illness on a patient's quality of life.

functional health patterns

light palpation

is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin (e.g., over an IV site).

POC is an acronym that stands for:

plan of care

Which of the following terms is NOT a part of the COLDSPA acronym?

pressure

Notes that nurses take to summarize how a patient is doing are called:

progress notes

What term is used to describe the subjective description of the percussion tone?

quality

In a history of present illness, which of the following are not usually considered?

reactions to medications

History of present illness

symptom intensity

history of present illness

symptom location

primary data source

the client

bimanual deep palpation

the extended fingers of the nondominant hand are placed over the dominant hand to use the pressure of both hands.

moderate palpation

to assess the size, shape, and consistency of abdominal organs.

A complete description of the present illness is essential to an accurate diagnosis when caring for a patient.

true

Accrediting agencies such as The Joint Commission or Departments of Health establish standards and audit patient records to evaluate the quality of care provided.

true

Effective communication with members of the health care team and verbal communication must be organized, complete, accurate, concise, and respectful

true

Falsifying a patient's record is considered a high-risk error in documentation.

true

The Joint Commission required each hospital to develop an ongoing objective review of patient records for continuous quality improvement and to demonstrate correction of any deficiencies noted during the review.

true

The health record is a legal document recording the patient's health status and any care they receive.

true

The use of electronic medical records allows several health care team members to view a patient's record simultaneously.

true

The use of electronic medical records significantly increases patient safety.

true