48.4 Documentation and Reporting

A nurse is participating in a committee that will select a universal nursing documentation for the hospital. What advantages would the committee consider when looking at the focus charting documentation​ format? A) Allows for checklists or flow sheets to record routine nursing tasks. B) Offers a complete perspective of the client and the client​'s care needs. C) Provides a structure for the progress notes. D) Ensures that the nursing focused assessment is the priority of care. E) Ensures that each nursing note includes​ data, action, and response.

A) Allows for checklists or flow sheets to record routine nursing tasks. B) Offers a complete perspective of the client and the client​'s care needs. C) Provides a structure for the progress notes.

A nurse needs to send a fax containing client protected health information​ (PHI) to another healthcare facility. Which actions by the nurse best protect the client​'s ​PHI? A) Checking the fax number is correct prior to sending B) Ensuring personal identifiable information is contained in the transmittal C) Receiving consent from the client to fax information D) Requiring the receiving agency send a signed receipt E) Using a coversheet with a disclaimer statement

A) Checking the fax number is correct prior to sending C) Receiving consent from the client to fax information D) Requiring the receiving agency send a signed receipt E) Using a coversheet with a disclaimer statement

A nurse is documenting in the client​'s chart and makes a recording mistake. Which action made by the nurse is the most​ appropriate? A) Drawing one line through the​ error, writing, and placing initials next to entry B) Drawing three lines through the error and signing next to the entry C) Using correction fluid on the error and signing next to the entry D) Crossing the error out with an "X" and placing initials next to the entry

A) Drawing one line through the​ error, writing, and placing initials next to entry

A nurse is documenting client protected health information​ (PHI) at a point of care computer terminal in the client​'s room. Keeping in mind that the client​'s room is​ private, which action by the nurse is acceptable regarding protecting the client​'s PHI once the nurse leaves the client​'s ​room? A) Exiting out of the client​'s PHI and logging off B) Remaining logged in to the computer because the client​'s room is private C) Minimizing the client​'s PHI on the screen but remaining logged in D) Exiting out of the client​'s PHI but remaining logged in

A) Exiting out of the client​'s PHI and logging off

A wound care nurse is invited to attend a client​'s care plan conference. What is true regarding a care plan​ conference? A) It is usually made up of a variety of disciplines. B) It is usually held upon the client​'s admission. C) It is usually hosted by the client​'s physician. D) It is usually unacceptable to invite family members.

A) It is usually made up of a variety of disciplines.

A novice nurse is hired to work on the telemetry unit and is reviewing the unit​'s policy on handoff communication and the use of the SHARE method. What is true regarding this​ method? ​ A) It provides timely feedback to staff who fail to follow the process. B) It ensures that the nurse uses his own narrative and charting during the transfer. C) It provides opportunity to ask questions during the transfer. D) It provides standardized training in the handoff process. E) It ensures that the nurse provides the essential content during the transfer.

A) It provides timely feedback to staff who fail to follow the process. C) It provides opportunity to ask questions during the transfer. D) It provides standardized training in the handoff process. E) It ensures that the nurse provides the essential content during the transfer.

The client​'s record is a legal document and usually is permissible in court as evidence.​ However, in some​ jurisdictions, the record is excluded as evidence. Which situation would exclude the client​'s record as​ evidence? A) The client refuses B) The prosecution refuses C) The hospital refuses D) The defense refuses

A) The client refuses

A student nurse is performing a clinical rotation and needs to access client information for an assignment at school. In which situations is it appropriate for the student nurse to have access to client​ information? A) When presenting client studies B) When studying for exams C) When presenting for clinical conferences D) When writing papers E) When participating in clinical rounds

A) When presenting client studies C) When presenting for clinical conferences D) When writing papers E) When participating in clinical rounds

A nurse is documenting in the​ client's chart and makes a recording mistake. Which action made by the nurse is the most​ appropriate? A) Crossing the error out with an​ X and placing initials next to the entry B) Drawing one line through the​ error, writing mistaken entry​, and placing initials next to entry C) Using correction fluid on the error and signing next to the entry D) Drawing three lines through the error and signing next to the entry

B) Drawing one line through the​ error, writing mistaken entry​, and placing initials next to entry

A nurse is documenting client information into the database of a​ problem-oriented medical record. Which client information is the nurse likely​ documenting? A) Spiritual needs B) Health history C) Plan of care D) Nursing diagnosis

B) Health history

When documenting client​ care, the nurse adds to the client problem​ list, plan of​ care, and progress notes. What is an advantage of this type of documentation​ system? A) Care providers from every discipline can easily locate the documentation forms. B) It encourages collaboration among all disciplines. C) It provides uniformity among disciplines utilizing the charting format. D) It is easy to locate the documentation specific to one​'s discipline.

B) It encourages collaboration among all disciplines.

A nurse working in the intensive care unit​ (ICU) needs to give a​ change-of-shift report. What is the most appropriate action by the nurse for this type of verbal reporting​ system? A) Elaborate on client background data B) Report a client​'s need for special emotional support C) State priorities of client care at the beginning D) Give details on routine care needs of the client

B) Report a client​'s need for special emotional support

A nurse educator is teaching a group of student nurses about correct documentation techniques. Which statements are appropriate for the nurse educator to include in the teaching​ session? A) ​"Use subjective and thorough​ descriptions." B) ​"Document in a timely​ manner." C) ​"Follow organizational policies to correct charting​ errors." D) ​"Do not document the​ client's actual​ words." E) ​"Document the​ client's response to​ interventions."

B) ​"Document in a timely​ manner." C) ​"Follow organizational policies to correct charting​ E) ​"Document the​ client's response to​ interventions."

A nurse is documenting client information in a​ source-oriented record. What disadvantage does this documentation system​ present? A) Care providers from each discipline have difficulty locating the forms on which to record data. B) Caregivers differ in their ability to use the required charting format. C) Information about a particular client problem is scattered throughout the chart. D) It is difficult to trace the information specific to each provider​'s discipline.

C) Information about a particular client problem is scattered throughout the chart.

A nurse decides to add narrative charting to the client​'s nursing progress note to make a more complete nursing progress note. The nurse​ writes, "The client wasn​'t hungry and didn​'t eat much." What document guideline is the nurse failing to​ use? A) Appropriateness B) Sequence C) Conciseness D) Accuracy

D) Accuracy