320 final Documentation PrepU

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

Reporting

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: factual statement. interpretation of data. important information. relevant data.

interpretation of data

A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? Every 3 hours Every 4 hours Daily As needed

As needed

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? Calling the client information desk to find out the room number of the family member Finding the emergency medical technicians who transported the family members and inquiring about the injuries Asking the emergency department nurse for information on the family member Accessing the electronic health record of the family member to find out extent of injury

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

What ensures continuity of care? reassessment critical thinking communication integration

Communication

Which is the primary purpose of client records? Communication Reimbursement Legal protection Performance improvement

Communication

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error? Immediately delete the incorrect documentation. Create an addendum with a correction. Contact information technology (IT) staff to make the correction. Contact the health care provider.

Create an addendum with a correction. - If the nurse is using an EMR and the documentation cannot be changed, an addendum will need to be written

A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? Admission sheet Admission nursing assessment Flow sheet Graphic record

Graphic record

A nurse is documenting a client's care in the electronic health record. This is the third entry being made by the nurse for the day. The nurse would sign the entry using which signature? Jane Smith, RN J. Smith, RN Jane Smith JS

J. Smith, RN When signing each entry, the nurse signs with the first initial, last name, and title.

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? Subjective data should be included when documenting. Objective data are what the client states about the problem. The plan includes interventions, evaluation, and response. Abnormal laboratory values are common items that are documented.

Subjective data should be included when documenting.

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator? Talking directly to the translator facilitates the transfer of information. Talking loudly helps the translator and the client understand the information better. It is always okay to not use a translator if a family member can do it. Translators may need additional explanations of medical terms.

Translators may need additional explanations of medical terms.

Which documentation by the nurse best supports the PIE charting system? Vomiting 250 mL undigested food, antiemetic given, no further vomiting States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea

Vomiting 250 mL undigested food, antiemetic given, no further vomiting

What dual purpose does an audit serve? communication and evaluation knowledge and quality education and confidentiality quality assurance and reimbursement

quality assurance and reimbursement

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse? "I will arrange access for you to review the record after you put your request in writing." "No, the physician will not give you access to review the records." "Are you questioning the care of your child?" "Only the client has the right to review the health care records."

"I will arrange access for you to review the record after you put your request in writing."

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse? "Legal policy requires nursing practice to be permanently integrated into the client record." "It would be easier to do it that way. You could develop a tool to use." "The facility requires us to document client care this way because of the computer application used." "The electronic health record we use does not allow us to use different formats."

"Legal policy requires nursing practice to be permanently integrated into the client record."

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A client has asked a nurse if he can read the documentation that his physician wrote in his chart. A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. A client who resides in Indiana has required hospitalization during a vacation in Hawaii

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

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? A never event A variance An audit A sentinel event

A variance

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? Inform the health care provider that a written order is needed. Write the order in the client's record. Call the pharmacy to have the order entered in the electronic record. Add the new order to the medication administration record.

Inform the health care provider that a written order is needed.

Which abbreviation is correct for use in documentation? PO Sub q Per os BT

PO

The nurse documents that a client does not have pain prior to the administration of pain medication. The client, however, requested medication for increasing postsurgical pain. What is the appropriate action to correct the pain assessment documented in the client's paper medical record? Scribble through the entry. Obtain white-out to cover the entry. Write over the entry in another color pen. Place one line through the entry and initial it.

Place one line through the entry and initial it.

Which statement regarding FOCUS charting is most accurate? The charting focuses on client strengths, problems, or needs. The charting focuses on the injury or illness only. Problem, intervention, evaluation (PIE) charting is used with FOCUS charting. Each note should include each section of the data, action, response (DAR) format of charting.

The charting focuses on client strengths, problems, or needs - DAR is the narrative note format for focus however not every section of DAR needs to be included for every entry

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? pain rating of 4 on a scale of 0-10 describes wound as itchy urine output 100 ml concerned with feeling tired

urine output 100 ml

A nurse is documenting the care given to a patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? Erase or use correcting fluid to completely delete the error. Mark the entry "mistaken entry"; add correct information; date and initial. Use a permanent marker to block out the mistaken entry and rewrite it. Remove the page with the error and rewrite the data on that page correctly.

Mark the entry "mistaken entry"; add correct information; date and initial.

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client 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? Source-oriented method PIE charting method Problem-oriented method Focus charting method

Problem-oriented method

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? SBAR SOAP PIE MAR

SBAR

Which is not a purpose of the client care record? To serve as a legal document To facilitate reimbursement To serve as a contract with the client To assist with care planning

To serve as a contract with the client

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply. what the client watched on television during the shift what time the nurse will return for the next shift any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders

any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders

Which are appropriate actions for protecting clients' identities? Select all that apply. Orient computer screens toward the public view. Ensure that clients' names on charts are visible to the public. Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.

Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: have the right to copy their health records. need to obtain legal representation to update their health records. can be punished for violating guidelines. are required to obtain health record information through their insurance company.

have the right to copy their health records.

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." "I am calling about the patient in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states: Some facilities do not require them on their plans of care. Rationales are only important while the nurse is in training. The use of rationales is not commonly practiced in the clinical setting. Although not written, the nurse must know or question the rationale before performing an action. The rationale is deleted to provide additional charting space in the computer system.

Although not written, the nurse must know or question the rationale before performing an action.

The nurse is tasked to organize weekly care plan conferences with other health care team members. Which would be appropriate items to include in this meeting? Select all that apply. A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made A review of a client's current progress in the plan of care A discussion of the meal plan for a client with diabetes A recommendation for pain management by the emergency department physician who admitted the client a week ago A conversation addressing the need for durable medical equipment when the client goes home

A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made A review of a client's current progress in the plan of care A discussion of the meal plan for a client with diabetes A conversation addressing the need for durable medical equipment when the client goes home

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 the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the 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 gauging the nurse's professional performance over time protecting the nurse and the hospital from litigation following up the incident with other members of the care team

identifying risks and ensuring future safety for clients

A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply. Documenting entries that have unidentifiable writers' names and titles Documenting entries that are up to date and comprehensive Recording the date and time of all entries Documenting entries that are subjective Using approved agency abbreviations

Documenting entries that are up to date and comprehensive Recording the date and time of all entries Using approved agency abbreviations

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information? Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." Client states expecting some pain, but it is more severe than anticipated. Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. Client is requesting pain medications, is grimacing, and is diaphoretic.

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? "Let me get that for you." "Only authorized persons are allowed to access client records." "The provider will need to give permission for you to review." "I am sorry I can't access that information."

"Only authorized persons are allowed to access client records."

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? "A coronary artery bypass graft will benefit your heart." "The CABG procedure will help identify nutritional needs." "A complete ablation of the biliary growth will decrease liver inflammation." "The CABG procedure will help increase intestinal motility and prevent constipation."

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

The nurse is performing a health assessment on a client at the clinic. Which data are gathered during the social history assessment? "Tell me what your biggest complaint is right now?" "Have you had any surgical procedures?" "Does heart disease run in your family?" "How many packs of cigarettes do you smoke per day?"

"How many packs of cigarettes do you smoke per day?"

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? "I am calling because the client receiving blood has developed dyspnea and had crackles." "This client has a medical history of heart failure." "It seems like this client has fluid volume overload." "I think the client would benefit from intravenous furosemide."

"I think the client would benefit from intravenous furosemide."

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? "I'm sorry, but patients are not allowed to copy their medical records." "I can make a copy of your record for you right now." "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." "I will need to check with our records department to get you a copy."

"I will need to check with our records department to get you a copy."

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate? "The benefit of CBE is less time needed on computer charting." "The benefit of CBE is that it demonstrates whether high-quality care is given." "CBE is the best way to protect against lawsuits." "CBE is a relatively new format of documentation in electronic health records."

"The benefit of CBE is less time needed on computer charting."

The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development? "The care plan is required for every client by The Joint Commission." "The care plan is the only way for nurses to document what they do." "The care plan provides additional documentation about the work of the nurse." "The care plan shows the medical diagnosis for the client."

"The care plan is required for every client by The Joint Commission."

A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift? "No medical issues overnight that require immediate attention." "The unlicensed assistive personnel turned the client every 2 hours last night, but the client should continue to be repositioned during the day." "The client had a good deal of anxiety last night and requested to be turned and repositioned frequently." "The client was very restless last night so you may need to call the health care provider today to get a prescription for the client's anxiety."

"The client had a good deal of anxiety last night and requested to be turned and repositioned frequently."

The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr. The client is NPO and has received morphine sulfate 4 mg IV for pain with a decrease of epigastric pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method? 125 mL/h of normal saline, NPO, pain 4/10 on pain scale with 4 mg IV morphine every 4 hours 4/10 pain on pain scale, epigastric pain; with reports of nausea NPO, 4/10 pain, epigastric pain, nausea 4/10 pain with nausea; on IV fluids

4/10 pain on pain scale, epigastric pain; with reports of nausea Charting by exception charts only that which falls outside the standard of care and norms. 125 mL/h of normal saline, NPO, pain 4/10 on pain scale with 4 mg IV morphine every 4 hours is incorrect because the IV fluids and morphine are expected to occur. NPO, 4/10 pain, epigastric pain, nausea is incorrect because NPO is expected. 4/10 pain with nausea; on IV fluids is incorrect because IV fluids are expected.

Which pieces of information should the nurse treat as confidential and not disclose? Select all that apply. A client's diagnosis linked to a disease outbreak A client's Social Security number Information about a client's past health conditions A client's address A deceased client's history for organ donation

A client's Social Security number Information about a client's past health conditions A client's address Client information that is considered confidential includes client names and all identifiers, such as address, telephone and fax number, Social Security number, and any other personal information. It also includes the reason the client is sick or in the hospital, office, or clinic, the assessments and treatments the client receives, and information about past health conditions. Exceptions to confidentiality include disclosure of client information for the purpose of tracking and notification of disease outbreaks and information about a deceased person's organ donation.

A nurse is using the SOAP format to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? A patient problem list Narrative notes describing the patient's condition Overall trends in patient status Planned interventions and patient outcomes

A patient problem list The SOAP format (Subjective data, Objective data, Assessment, Plan) is used to organize entries in the progress notes of a POMR. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Overall trends in patient status can be seen immediately when using CBE, not SOAP charting. Planned interventions and patient-expected outcomes are the focus of the case management model.

The nurse is using the ISBARR format to report a surgical client's deteriorating condition to a health care provider. Which actions would the nurse perform when using this guide? Select all that apply. The nurse asks the health care provider to describe the admitting diagnosis of the client. After introductions, the nurse states the client name, room number, and problem. The nurse asks the health care provider to estimate the discharge date for the client. The nurse asks the health care provider to comment on the present situation before giving recommendations. The nurse states that the client's condition "could be life-threatening." The nurse reads back the physician's new orders at the conclusion of the call.

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

The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. Which action by the nurse is most appropriate? Assess the triggers from the data. Document the findings on an occurrence report. Provide a comprehensive written report to the client ombudsperson. Repeat the minimum data set in 2 weeks.

Assess the triggers from the data. Once the minimum data set is complete, it will identify elements or triggers for issues that the resident either has or is at risk for developing. The information should not be documented on an occurrence report, as it is not is a comprehensive written report required to be sent. There is no need to complete the minimum data set in 2 weeks unless the resident has a significant change in condition.

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation? Fill out an incident report. Attach a copy of the incident report to the chart. Stop the infusion and document the time. Report the error to the primary provider.

Attach a copy of the incident report to the chart.

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the correct ISBARR order. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." "You want me to discontinue the PCA pump until you see him tonight at patient rounds." "I am Rosa Clark, an RN working on the second floor of South Street Hospital." "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer." "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

DAEBFC "I am Rosa Clark, an RN working on the second floor of South Street Hospital. I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer. Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer. Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump. I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered. You want me to discontinue the PCA pump until you see him tonight at patient rounds."

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edematous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"? PIE FOCUS Narrative Exception

FOCUS The nurse used FOCUS charting, as it gives priority attention to the client's current or changed behavior. PIE charting occurs when the nurse records the client's progress under the headings of problem, intervention, and evaluation. Narrative charting content resembles a log or journal entry. Charting by exception is charting only abnormal assessment findings that deviate from a standard norm. Therefore, this nurse is not demonstrating PIE, narrative, or exception charting.

Which statement is not true regarding a medication administration record (MAR)? If the client declines the dose, the nurse does not have to document this on the MAR. The MAR distinguishes between routine and "as needed" medications. The MAR identifies routine times for medication administration. After using an electronic MAR, the nurse should log off.

If the client declines the dose, the nurse does not have to document this on the MAR. - If a client declines a dose, the nurse should circle that dose and write a note as to why the nurse did not administer it.

Which are high-risk errors in documentation? Select all that apply. Inadequate admission assessment Failure to document completely Charting in advance Batch charting Falsifying client records

Inadequate admission assessment Failure to document completely Charting in advance Falsifying client records High-risk errors include falsifying client records, charting in advance, failure to record changes in a client's condition, failure to document that the physician was notified when a client's condition changed, inadequate admission assessment, incomplete documentation, and failure to follow agency standards or policies on documentation.

Which is a drawback to the type of documentation known as charting by exception? Interference with standardized assessments Less interdisciplinary communication Issues related to high-quality care should a negligence claim arise Increased time required to document information

Issues related to high-quality care should a negligence claim arise

The nurse is caring for a client who is prescribed a pain medication by mouth every 4 to 6 hours. When assessing pain status, the client states not wanting to take any medication right now. Which principle should the nurse consider when documenting interventions regarding medication administration for this client? Medication should be documented along with the time and the amount given or not given each time medication is scheduled to be administered. The client's pain should be documented on a scale of 0 to 10 when documenting the administration of pain medication. Medication that is not administered should be documented along with the reason. Steps taken to encourage the client to comply should be documented along with assessment findings.

Medication that is not administered should be documented along with the reason. - that other answer is wrong bc it says as scheduled meaning administration hasn't occurred yet

Which principle should guide the nurse's documentation of entries on the client's health care record? Correcting fluid is used rather than erasing errors. Documentation does not include photographs. Precise measurements should be used rather than approximations. Nurses should not refer to the names of physicians.

Precise measurements should be used rather than approximations.

The nurse receives a verbal prescription from a health care provider during an emergency situation. Which action(s) should be taken by the nurse? Select all that apply. Read back the prescription. Record the date and time of the prescription. Include V.O. with the health care provider's name on the prescription. Have the health care provider review and sign the prescription during the emergency. Record the prescription on the pharmacy discrepancy sheet.

Read back the prescription. Record the date and time of the prescription. Include V.O. with the health care provider's name on the prescription. pharmacy discrepancy sheets are used to record discrepancies in medication inventories, which could indicate diversion, or theft, of prescription medications.

The nurse is providing documentation for the care rendered to clients. Which characteristics identify documentation as effective? Select all that apply. Readable Thoughtful Timely Clear, concise, and complete Accurate, relevant, and lengthy Retrievable on a temporary basis

Readable Thoughtful Timely Clear, concise, and complete - documentation should be accessible, accurate, relevant, consistent, auditable, clear, concise (not lengthy), complete, legible/readable, thoughtful, timely, contemporaneous, sequential, and retrievable on a permanent (not temporary) basis.

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? Remind the UAP about the client's right to privacy. Report the UAP to the nurse manager. Notify the client relations department about the breach of privacy. Document the UAP's conversation.

Remind the UAP about the client's right to privacy. -All other actions are appropriate, but do not immediately protect the client's privacy.

The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? Review the hospital's process for allowing clients to view their health care records. Access the health care record at the bedside and show the client how to navigate the electronic health record. Discuss how the hospital can be fined for allowing clients to view their health care records. Explain that only a paper copy of the health care record can be viewed by the client.

Review the hospital's process for allowing clients to view their health care records

Which actions should the nurse take before making an entry in a client's record? Select all that apply. Reviewing the agency's list of approved abbreviations Choosing the charting format that the nurse prefers Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting Checking that clients' names are not identified within the chart forms

Reviewing the agency's list of approved abbreviations Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting

A health care facility plans to evaluate and revise the plan of care for a client based on the client's health care records. The physician, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details? FOCUS charting narrative charting PIE charting SOAP charting

SOAP charting In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. Narrative charting is time-consuming to write and read, as it involves sorting through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the health care provider's order sheet. What is the nurse's BEST response? State: "Thank you for taking care of this! I'll be happy to document the order on the health care provider's order sheet." Get a second nurse to listen to the order, and after writing the order on the health care provider order sheet, have both nurses sign it. State: "I am sorry, but VOs can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." Try calling another resident for the order or wait until the next shift.

State: "I am sorry, but VOs can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly."

The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which of the following should the nurse record in his or her charting? Select all that apply. The client is crying. The client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today." The client seems depressed. The client is suicidal. The client is in a bad mood.

The client is crying. The client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today." When documenting observations of client behavior, the nurse must maintain objectivity by describing the actual behaviors, rather than attempting to interpret the behaviors. For example, the nurse should not describe the client as depressed or angry. The nurse should document any statements made directly by the client.

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? The nurse can accept verbal orders to provide immediate care and record once the client is stable. The provider can input orders remotely into the EHR system for the nurse to retrieve. The nurse can implement care once written orders are received from the provider. The client must be stabilized before the nurse can obtain any orders from the provider.

The nurse can accept verbal orders to provide immediate care and record once the client is stable.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process? The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. The nurse meets with nurses or other health care professionals to discuss some aspect of client care. The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. The nurse sends or directs someone to take action in a specific nursing care problem.

The nurse meets with nurses or other health care professionals to discuss some aspect of client care. - A nursing care conference is a meeting of nurses to discuss some aspect of a client's care.

A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy? Do not release any information to the insurance company. Use minimum disclosure policy to release the information. Refer the insurance agency directly to the client. Release the full medical record to expedite payment.

Use minimum disclosure policy to release the information.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a client who is homebound and needs skilled nursing care a client whose rehabilitation potential is not good a client whose status is stabilized a client who is not making progress in expected outcomes of care

a client who is homebound and needs skilled nursing care

The client record is utilized for many purposes. Which might be uses for the client record? Select all that apply. education of student nurses reimbursement for services research giving information over the phone when unidentified callers call the hospital unit education for medical students

education of student nurses reimbursement for services research education for medical students

A client's record can be more accurate if the nurse: charts at least every 6 hours. uses point-of-care documentation. summarizes client care at the end of the shift. delegates charting appropriately.

uses point-of-care documentation. - Point-of-care documentation takes place as care occurs, thus enhancing accuracy.

HIPAA allows incidental disclosures of client 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 client health information. What are examples of this type of client health information disclosure? Select all that apply. The nurse uses sign-in sheets that contain information about the reason for the client visit. A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. The nurse uses white boards on an unlimited basis. The nurse uses x-ray light boards that can be seen by passersby; however, client 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 client visit. The nurse leaves a detailed appointment reminder message on a client's voice mail.

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, client 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 client visit.

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply. "I will write, print, or type information legibly." "I will use only agency-approved abbreviations." "I will draw a straight line through any blank space." "I will stay logged in on the computer until the end of my shift." "I will elaborate on the details on my entry in the clients' records."

"I will write, print, or type information legibly." "I will use only agency-approved abbreviations." "I will draw a straight line through any blank space."

A friend of a nurse calls and tells the nurse that his girlfriend's father was just admitted to the hospital as a patient, and he wants the nurse to provide information about the man's condition. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks." "Because of HIPAA, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" "Why do you think Sue isn't talking about her worries?"

"Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks."

Which statement by the nurse is the best example of an internal communication strategy the nurse should use to discuss the use of new equipment, client care problems, and change in policies? "We will discuss the new policies at the change-of-shift report." "You will demonstrate the use of the cardiac monitor on the nursing rounds." "You will see the procedure for using the new equipment in the client assignments." "We will be having a team conference to discuss concerns that clients' relatives have raised."

"We will be having a team conference to discuss concerns that clients' relatives have raised." -Team conferences are effective communication strategies to discuss the relatives' concerns because this usually involves the multidisciplinary team and the relatives could be involved. Change-of-shift report is incorrect since this is only a summary of each client's condition and current status of care in a discussion between the personnel of the outgoing and incoming shifts. Client assignment identifies the clients for whom the staff person is responsible and describes their care and is therefore incorrect. Nursing rounds is incorrect since this strategy provides the staff the opportunity to observe and converse in the client's presence and boost the client's confidence.

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with appendicitis. The health care provider has ordered 10-mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follow recommended guidelines? Select all that apply. 6/12/20 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN 6/12/20 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN 6/12/20 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN

6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN

Which note includes all elements of a SOAP note? Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness. Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess.

Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

When may a health institution release a PHI for purposes other than treatment, payment, and routine health care operations, without the patient's signed authorization? Select all that apply. News media are preparing a report on the condition of a patient who is a public figure. Data are needed for the tracking and notification of disease outbreaks. Protected health information is needed by a coroner. Child abuse and neglect are suspected. Protected health information is needed to facilitate organ donation. The sister of a patient with Alzheimer's disease wants to help provide care.

Data are needed for the tracking and notification of disease outbreaks. Protected health information is needed by a coroner. Child abuse and neglect are suspected. Protected health information is needed to facilitate organ donation.

The nurse is preparing to call a health care provider to report a significant decrease in a client's oxygen saturation level. What action should the nurse take first? Obtain all needed information to give report. Document all findings in the electronic health record. Report the change to the health care provider using ISBAR. Request another nurse stay with the client while the report is called.

Obtain all needed information to give report. The nurse should obtain all needed information first before calling the health care provider, and use the ISBAR format. The nurse will need to document all the findings in the client's record, but should contact the health care provider before documenting due to the significant change in oxygen levels. Asking another nurse to stay with the client is appropriate, but only after all information is gathered.

A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply. S: The nurse handling the transfer describes the client situation to the new nurse. S: The nurse discusses the client's symptoms with the new nurse in charge. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse explains the rules of the new facility to the client. R: The nurse gives recommendations for future care to the new nurse in charge.

S: The nurse handling the transfer describes the client situation to the new nurse B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse gives recommendations for future care to the new nurse in charge.

The nurse is documenting a progress note that relates to a client's health problem. What form of documentation is the nurse writing? PIE note flow sheet narrative note SOAP note

SOAP note SOAP note is a progress note that relates to only one health problem.

While assisting a client with a delivery, a nurse takes a photo of the newborn and posts it on a social media website. What action may occur related to this privacy violation? The nurse could be fined or even go to jail for violating HIPAA. No action will be taken as long as the parents don't find out. There will be no repercussions if the nurse takes the photo down from the social media page. The nurse could be fired but would not face criminal charges or jail time.

The nurse could be fined or even go to jail for violating HIPAA.

The nurse is completing documentation for a newly admitted client. Which entries should the nurse include in charting? Select all that apply. The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. "I feel something is going on the client isn't telling me." The client was overheard telling a family member about more bleeding than reported The dressing has a 5 cm area of bloody drainage The client's pupils are equal, reactive, to light and accommodation

The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. The client was overheard telling a family member about more bleeding than reported The dressing has a 5 cm area of bloody drainage The client's pupils are equal, reactive, to light and accommodation Entries must be accurate. Nurses must chart only observations that they have seen, heard, smelled, or felt. An observation made by another health professional must be clearly identified as such.

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? Write a narrative note in the designated nursing section. Place the narrative note chronologically after the respiratory therapist's note. Review the laboratory results under the physician section. Use a critical pathway to document the physical assessment.

Write a narrative note in the designated nursing section. Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the physician section. Critical pathways are not used to document physical assessments.

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? charting by exception (CBE) FOCUS charting problem, intervention, evaluation (PIE) charting variance charting

charting by exception (CBE) - Charting by exception (CBE) 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 the narrative notes. Charting by exception decreases charting time. FOCUS charting does not use a problem list of nursing or medical diagnoses, but incorporates many aspects of the client and client care into a FOCUS column. The focus may be a client strength, problem, or need. Problem, intervention, evaluation (PIE) charting incorporates the plan of care into the progress note, and problems are identified by an assigned number. Variance charting is used when clients fail to meet an expected outcome, or when a planned intervention is not implemented in the case management model.