#4 Documenting and Reporting- Prep U's

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? -Call the pharmacy to have the order entered in the electronic record. -Write the order in the client's record. -Add the new order to the medication administration record. -Inform the health care provider that a written order is needed.

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

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? One U of glucose 1 bottle of glucose 1 Unit of glucose 1U of glucose

1 Unit of glucose

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

2130

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate? Take the parent to the client's room and have the client give the requested information. Explain the reasons for the hospitalization, but give no further information. Provide the information to the parent. Ask the client if information can be given to the parent.

Ask the client if information can be given to the parent.

Which flow sheet provides the health care provider with information on an ongoing record of fluid loss? Health assessment flow sheet Vital signs graphic sheet Intake and output graphic sheet Critical care flow sheet

Intake and output graphic sheet

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? Omitting clients' responses to nursing interventions Recording nursing interventions Documenting clients' health histories and discharge planning Identifying nursing diagnoses or clients' needs

Omitting client's responses to nursing interventions

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

Precise measurements should be used rather than approximations.

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? The client is coughing and experiencing severe heartburn in the morning. The client has a history of severe complaints in the morning. The client reports waking up this morning with a severe headache. The client has symptoms in the morning associated with a heart attack.

The client reports waking up this morning with a severe headache.

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? Lung sounds The abdominal area Heart rate and rhythm The lower extremities

The lower extremities

Which documentation tool will the nurse use to record the client's vital signs every 4 hours? acuity charting forms a 24-hour fluid balance record a medication record a flow sheet

a flow sheet

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of: a referral. reporting. conferring. a consultation.

a referral

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation? charting by exception SOAP focus narrative

charting by exception

What ensures continuity of care? communication integration reassessment critical thinking

communication

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

urine output 100 ml

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family." "Any information that can identify a person is considered a breach of client privacy." "You may continue to post about a client, as long as you do not use the client's name." "All aspects of clinical practice are confidential and should not be discussed."

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

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate? "Be sure to put the client's name and room number on all paperwork." "You can get an electronic printout of client lab data to take with you." "Clipboards with client data should not leave the unit." "Be sure to write down specific information for your clinical paperwork."

"Clipboards with client data should not leave the unit."

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? "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 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. 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 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."

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in charting? "If I make an error, I draw a single line through it and put my initials by it." "If I make an error, I can draw a red circle around it." "If I make an error, I use white-out on it." "If I make an error, I have to rewrite the entire entry."

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

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? "It will allow for us to see the client and possibly increase client participation in care." "It will give me a better sense of what my workload will be today." "It makes our client feel like we care, especially if we start the day off with a clean room." "It will let me see everything that has been done and things that need to be done."

"It will allow for us to see the client and possibly increase client participation in care."

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? "It will give me a better sense of what my workload will be today." "It will let me see everything that has been done and things that need to be done." "It will allow for us to see the client and possibly increase client participation in care." "It makes our client feel like we care, especially if we start the day off with a clean room."

"It will allow for us to see the client and possibly increase client participation in care."

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

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

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records? "I can share the clients' medical records with the health care team." "The clients' medical records are an obstruction to research and education." "The clients' medical records provide data for legal evidence." "The clients' health records should be used to promote reimbursement from insurance companies"

"The clients' medical records are an obstruction to research and education."

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: -The rationale is deleted to provide additional charting space in the computer system. -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. -Some facilities do not require them on their plans of care.

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

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? Client's record and occurrence report Care plan and client's record Critical pathway and care plan Occurrence report and critical pathway

Clients record and occurence report

What is the primary purpose of the client record? Education Communication Research Advocacy

Communication

Which statement about client records and documentation is correct? Nurses should not document progress notes in a client's record. Clients should keep the original record at home in a fireproof safe. Physicians will not review nurses' documentation in the client's record. Communication is the primary purpose of client records.

Communication is the primary purpose of client records.

Which statement is not true regarding a medication administration record (MAR)? After using an electronic MAR, the nurse should log off. The MAR identifies routine times for medication administration. 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.

If the client declines the dose, the nurse does not have to document this on the MAR.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? Recording nursing interventions Omitting clients' responses to nursing interventions Documenting clients' health histories and discharge planning Identifying nursing diagnoses or clients' needs

Omitting clients' responses to nursing interventions

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? Document the UAP's conversation. Remind the UAP about the client's right to privacy. Notify the client relations department about the breach of privacy. Report the UAP to the nurse manager.

Remind the UAP about the client's right to 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? Access the health care record at the bedside and show the client how to navigate the electronic health record. Explain that only a paper copy of the health care record can be viewed by the client. Discuss how the hospital can be fined for allowing clients to view their health care records. Review the hospital's process for allowing clients to view their health care records.

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

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 MAR SOAP PIE

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 nurse implementing? SOAP charting narrative charting PIE charting FOCUS charting

SOAP charting

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

Subjective data should be included when documenting.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? objectivity reimbursement subjectivity organization

Subjectivity

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? Submitting a written notice to all clients identifying the uses and disclosures of their health information Releasing the client's entire health record when only portions of the information are needed Disclosing client health information for research purposes after obtaining permission from the client's physician Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information

Submitting a written notice to all clients identifying the uses and disclosures of their health information: Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the physician's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations.

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? -The client reports that on a scale of 0 to 10, the current pain is a 3. -The client appears comfortable and is resting adequately and appears to not be in acute distress. -The client is receiving sufficient relief from pain medication, stating no pain in either knee. -The client appears to have a low tolerance for pain and frequently reports intense pain.

The client reports that on a scale of 0 to 10, the current pain is a 3.

Which finding from a nursing audit reflects high standards for client safety and institutional health care? -The nurse documents clients' responses to nursing interventions. -The nurse fails to adequately complete data on clients' health histories and discharge planning. -The nurse records inappropriate nursing interventions. -The nurse fails to identify the nursing diagnoses or clients' needs.

The nurse documents clients' responses to nursing interventions.

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, 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 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 meets with nurses or other health care professionals to discuss some aspect of client care.

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 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 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.

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? Refer the insurance agency directly to the client. Do not release any information to the insurance company. Release the full medical record to expedite payment. Use minimum disclosure policy to release the information.

Use minimum disclosure policy to release the information.

Which strategy would provide the most effective form of change of shift report? Providing the oncoming nurse the client's clipboard prior to leaving the unit. Discussing the client's visitors and complaints during the prior shift. Utilizing a reporting form and allowing time for any questions. Recording the report for the oncoming shift prior to leaving the unit.

Utilizing a reporting form and allowing time for any questions.

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

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

Write a narrative note in the designated nursing section

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: ensuring that abbreviations are understandable to clients who may seek access to their health records. limiting abbreviations to those approved for use by the institution. using only abbreviations whose meaning is self-evident to an educated health professional. using only those abbreviations that are defined in full at another location in the client's chart.

a) limiting abbreviations to those approved for use by the institution. Explanation:In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.

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 time the nurse will return for the next shift any abnormal occurrences with the client during the shift current orders identifying demographics, including diagnosis what the client watched on television during the shift

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

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

b) Incident report Explanation:An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse

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

have the right to copy their health records.

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? -following up the incident with other members of the care team -gauging the nurse's professional performance over time -identifying risks and ensuring future safety for clients -protecting the nurse and the hospital from litigation

identifying risks and ensuring future safety for clients Explanation:Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team. (less)

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

limiting abbreviations to those approved for use by the institution.

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan? data base plan of care progress notes problem list

progress notes

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

quality assurance and reimbursement

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? -health care professionals of the facility -any family member of the client -those directly involved in the client's care -close friends of the client

those directly involved in the client's care