Assessment ch.4: Validating and Documenting Data
During a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?
"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." Documentation should be as objective and precise as possible. Answers A and B attribute the client's behavior to being agitated and upset, both of which are terms lacking in precision and objectivity. Answer D is more objective, but answer C provides the most detailed, objective account of what transpired.
Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline." The nurse should record patient findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. The nurse should also avoid generalizations such as "seems comfortable today." The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner.
A nurse who is new to the health clinic and who recently graduated from a nursing program tells a client at the end of an interview that data the nurse has just collected from the client needs to be validated. The client, an elderly gentleman, gives the nurse a strange look and says, "Validate my data? What does that mean?" How should the nurse respond to this client?
"It means I need to make sure that all the information I gathered today is reliable and accurate." Validation of data is the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate. Validation does not mean that the nurse must retake all of the client's vital signs, have the physician check the patient's chart, or have the client sign a statement.
What are the purposes of them medical record? Select all that apply
Legal document Communication between health care members Quality assurance Research The medical record serves multiple purposes. In addition to being a legal document, the medical record is used for communication among health team members, care planning, quality assurance, financial reimbursement, education, and research.
Which assessment is most likely performed when a client is admitted to the hospital?
Comprehensive A comprehensive assessment of the client is performed by a hospital nurse on admission. A shift assessment is performed at the beginning of each shift. A focused assessment is a very brief assessment of potential problems. An abbreviated assessment is a term not commonly used but is similar to a focused assessment.
EHR: Electronic Health Record
Computer‐based documentation (EHR v. EMR) - Databases can link to other documents and health care departments - Eliminates repetition of collection of similar data - Nurses are involved in selecting and developing software systems and databases - Improves quality, safety and efficiency of care while reducing disparities - Must ensure privacy and security of data
Steps of validation
Deciding whether data requires validation • Determining ways to validate the data • Identifying areas where data are missing
A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?
Details are often missing CBE may pose legal problems, because details are often missing. CBE does not omit subjective assessment, CBE is an ethical form of charting, and the question does not indicate that the assessment skills of the nurse are lacking in any form.
Data Requiring Validation
Discrepancies or gaps between subjective and objective data - Client reports feeling happy but appears sad • Discrepancies in what the client says at one time versus another time - Variations in past history • Abnormal and/or inconsistent findings - Temp 104 degrees but skin is not warm
Assessment Forms for Documentation
Initial assessment form Frequent or ongoing assessment form Focused or specialty area assessment form
How does the client's medical record affect financial reimbursement?
Insurance companies audit client records to ensure that billing is accurate Detailed charting of assessments and necessary interventions often can support approval for additional hospital days. Lack of appropriate charting can influence whether financial payment will be authorized. This makes the other three choices incorrect.
A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?
It allows several health team members to view the patient record simultaneously. Electronic medical records allow several health care team members to view the patient record simultaneously.
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
It provides quick access to abnormal findings. Charting by exception provides quick access to abnormal findings as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.
The nurse enters a client's room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse's best action?
Leave the room to obtain another armband for the client. The nurse should obtain another armband for the client; that's the safest action. Confirming identity with visitors does not meet national client safety standards. Just asking the client for name and birth date means that the barcode system is bypassed; this is not necessary. The medications are scheduled, not emergent, so the nurse has time to get another armband and avoid a barcode override. Scanning the barcode on a chart does not ensure the client in the room is the right client. Another client could have wandered into this client's room.
A nurse is caring for a patient who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called:
charting by exception Charting by exception uses predetermined standards and norms to record only significant assessment data, and only abnormal findings require additional documentation. Narrative charting is done using unstructured paragraphs to record assessments and other activities. Pie charting includes stating the problem, interventions, and evaluation. Batch charting is waiting until the end of shift or after all patients have been assessed to chart.
A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply):
concise accurate timely complete organized
Narrative charting
done using unstructured paragraphs to record assessments and other activities.
If the nurse makes an error while documenting findings on a client's record, the nurse should
draw a line through the error, writing "error" and initialing. Errors in documentation are usually corrected by drawing one line through the entry, writing "error," and initialing the entry. Never obliterate the error with white paint or tape, an eraser, or a marking pen. Keep in mind that the health record is a legal document.
Frequent or ongoing assessment form
flow charts that help staff to record and retrieve data for frequent reassessments
Focused or specialty area assessment form
focused on one major area of the body for clients who have a particular problem
In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed
focused. Some institutions may use assessment forms that are focused on one major area of the body for clients who have a particular problem. These forms are usually abbreviated versions of admission data sheets, with specific assessment data related to the purpose of the assessment.
Pie charting
includes stating the problem, interventions, and evaluation.
Batch charting
is waiting until the end of shift or after all patients have been assessed to chart.
Charting by exception
uses predetermined standards and norms to record only significant assessment data, and only abnormal findings require additional documentation.
The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should
validate all data before documentation of the data. Validation of data verifies the assessment data that you have gathered from the client. It consists of determining which data require validation, implementing techniques to validate, and identifying areas that require further assessment data.
Steps of validating data:
• Deciding whether data requires validation • Methods of validation • Identification of areas for which data are missing
Verbal Communication of Findings
• Use a standardized method of data communication such as SBAR. • Communicate face to face with good eye contact. • Allow time for the receiver to ask questions. • Provide documentation of the data you are sharing. • Validate what the receiver has heard by questioning or asking the receiver to summarize your report. • When reporting over a telephone, ask the receiver to read back what the receiver heard you report and document the phone call with time, receiver, sender and information shared.
The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear." Use phrases instead of sentences to record data. For example, avoid recording: "The client's lung sounds were clear both in the right and left lungs." Instead record: "Bilateral lung sounds clear.
A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?
Ask the other nurse to read back what first nurse reported When reporting over a telephone, ask the receiver to read back what he or she heard you report and document the phone call with time, receiver, sender, and information shared. It would not be feasible to communicate face to face or provide documentation when speaking on the phone. Also, it would not be feasible or appropriate to have the attending physician speak with the other nurse, as the physician may not be available and would not likely be able to clarify the first nurse's assessment findings anyway.
The nurse is reviewing the patient's medical record. Which of the following does the nurse recognize as accurate documentation? (Select all that apply.)
Bowel sounds are hyperactive in all 4 quadrants. Coarse rhonchi noted throughout lung fields Left dorsalis pedis pulse weaker than right. Accurate documentation is detailed and explicit, such as the information regarding bowel sounds, lung sounds, and pedal pulses. Examples of ambiguous documentation include the data regarding pain - a pain rating should be specified. Specific descriptions should be documented to support the judgment of confusion and inappropriate behavior.
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 Charting by exception 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 patient and patient care into a focus column. The focus may be a patient 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 patients fail to meet an expected outcome or a planned intervention is not implemented in the case management model.
A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which of the following is an example of a written form of communication that the nurse should use?
Checklists The nurses can use the checklist method to share the client's health status with other health personnel involved in the client's care. Some other examples of written forms of communication include the nursing care plan, the nursing Kardex, and flow sheets. Notepads, e-mails, and SMSes are not examples of written forms of communication that the nurses should follow.
A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?
Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. As this is subjective data, the nurse should record it as the "client reports" instead of the "client has," to clarify that this is based on the client's perception. The nurse should use phrases instead of sentences for brevity. Finally, the nurse should record complete information and details for all client symptoms or experiences, not just, "Client reports headache."
The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?
Client safety increases Although implementing a computerized system is expensive and requires much planning and education, such systems significantly increase client safety. Computerized medical records do not decrease client safety, make physician notes more secure, or verify pharmacy orders.
Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?
Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10 Documentation should be concise and precise. The nurse should record what the client tells her in detail. Nurses should not make judgments or diagnosis about the information gathered until all data has been collected and validated. The use of the statement "within normal limits" should not be used-the nurse should document the actual data that was collected.
A nurse has just finished taking a client's vital signs and is comparing the results with those from his previous visit 3 months ago. Which of the following situations would require the nurse to validate the data?
Client's weight was 200 lb (91 kg) 3 months ago but 125 lb (57 kg) today Data should be validated when there are discrepancies or gaps between subjective and objective data or between what the client says at one time versus another. Also, data should be validated when there are findings that are very abnormal and/or inconsistent with other findings. In this case, the client's weight as measured today is highly inconsistent with the previous measurement from 3 months ago. It is not normal for someone to lose 75 lb (34kg) in just 3 months. Therefore, the nurse should validate the new measure by retaking the client's weight on a different scale or asking the client whether he has experienced any significant weight loss recently. All of the other findings are reasonably consistent with those from the previous visit.
What is the primary purpose of the patient record?
Communication The primary purpose of the patient record is to help healthcare professionals from different disciplines communicate with one another.
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing The medical record can be used as a legal document to provide evidence of wrongdoing. Quality assurance is conducted to determine whether standards of care are provided to patients and documented in the medical record. Various members of the healthcare team document in the medical record to communicate information and make care decisions and plan for patient discharge. Information in the patient's medical record is used to determine reimbursement by Medicare, Medicaid, workers' compensation insurance, and third-party insurance companies for care.
The nurse caring for six clients enters the room of a client who underwent gastrointestinal surgery and assesses vital signs, the abdominal wound, and auscultates bowel sounds before seeing the next client. Which type of assessment did this nurse perform on the client?
Focused The nurse performed a focused assessment to quickly assess for anticipated problems related to the medical diagnosis. This client underwent gastrointestinal surgery; therefore a focused abdominal assessment is warranted. A head to toe assessment is a type of comprehensive physical assessment. A comprehensive assessment is performed on admission and includes physical data, history, and psychosocial data. The shift assessment is performed at the beginning of each shift and includes an abbreviated exam of the client such as auscultation of heart and lungs and abdomen, assessment of circulation, and level of consciousness.
A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?
Focused Some institutions may use assessment forms that are focused on one major area of the body for clients who have a particular problem. Examples include cardiovascular or neurologic assessment documentation forms. An assessment flow chart allows for rapid comparison of recorded assessment data from one time period to the next. Progress notes may be used to document unusual events, responses, significant observations, or interactions because the data are inappropriate for flow records. The nursing minimum data set form has a cued format that prompts the nurse for specific criteria; it is usually computerized and is commonly used in long-term care facilities.
On reviewing a client's database following a physical examination, a nurse realizes that the client's weight has been steadily increasing over her past three visits. What follow-up question would be best for the nurse to pose to the client based on this finding?
Has your diet or exercise changed significantly in the past year? The patient's record clearly indicates that she has been gaining weight recently. The most logical area for the nurse to follow up on is diet and exercise. Although stress can lead to overeating, it is not necessarily the cause and thus should not be the primary focus of the follow-up. Diabetes, which features symptoms of extreme thirst and frequent voiding, and heart disease, which can be indicated by chest pain, are associated with obesity but should not be the primary focus.
The nurse is reviewing the patient's medical record. Which does the nurse recognize as accurate documentation?
Hyperactive bowel sounds are heard in all four quadrants. Accurate documentation is detailed and explicit. The nurse would recognize bowel sounds are hyperactive in all four quadrants as accurate documentation. The three remaining options are judgment without specific supporting information. The patient's weight and pain rating should be specified. Specific comments and behaviors should be documented to support the judgment of confusion and combativeness.
When charting by exception is used in a health care agency, the most important aspect of this method is what?
Identifying the standards and norms for the institution Clearly identifying the standards and norms and educating all users takes time and significant commitment from the agency using charting by exception. Organizing new forms for the nursing staff, training new nurses, and acquiring teachers for agency staff may be important, but they are not the most important aspect of this method.
When documenting the care of a patient, 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. 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 patient's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, patients need the assistance of a member of the care team when reviewing their chart.
The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record patient conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record patient conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
What is the nurse's best defense if a patient alleges nursing negligence?
Patient's record The patient record is the only permanent legal document that details the nurse's interactions with the patient. It is the best defense if a patient or patient surrogate alleges nursing negligence.
In order to help out the staff in completing admission tasks during a busy shift, the charge nurse is completing the admission database for a staff nurse. What is the charge nurse's best action?
Place the completed assessment in the medical record. The database should be placed in the medical record for access by all healthcare professionals who may need to review the client's information. The nurse should allow some time for documentation of findings and analysis of data. In addition to positive findings, it is essential to document absence of findings because, in the legal world, "if it's not documented, it's not done." The database should be completed in its entirety on admission. The client may be young, but an initial fall assessment score should be assessed.
A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?
Progress notes In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.
The nurse manager at an extended care facility is incorporating bar code scanners into client care. Bar code scanners have been utilized in client care to address which issue of quality hospital care?
Reduction in medical error The main issues in quality hospital care include evidence-based medicine, quality assurance, medical ethics, and the reduction in medical error. Bar code scanners are utilized to decreased the risk of a medication administration error.
A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The patient's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Repeating the measurement with a different sphygmomanometer and stethoscope The most appropriate method of validation in this case would be to simply retake the client's blood pressure with a different sphygmomanometer and stethoscope. Given the nurse's work experience, it is unlikely that the discrepancy is due to improper technique, thus having the physician take the client's blood pressure is not warranted. Given the client's long history of hypertension and that his weight has not changed, it seems unlikely that the discrepancy could be explained by improved diet or exercise.
S: B: A: R:
S: Situation: What is happening now, why are you calling. Specifics about the patient & condition • B: Background: Describe the events that led up to the current situation • A: Assessment: Subjective and objective data • R: Recommendation: Suggest what you believe needs to be done for the client based on your assessment findings (come see pt; new orders)
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?
SBAR Verbal communication of a change in a client's condition would be most effective if the nurse used SBAR as it provides a standardized format and structure for communication. PIE, DAR and SOAP are all types of progress notes.
A nurse is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect? Select all that apply.
The client's family history of cancer The client's weight-lifting routine The client's occupation Subjective data include information that the client or significant others tell the nurse and typically consist of biographic data, present health concern(s) and symptoms, personal health history, family history, and lifestyle and health practices information. Objective data are what the nurse observes through inspection, palpation, percussion, or auscultation.
A nurse is having a new client complete a health history form and sign a form acknowledging his rights under the Health Insurance Portability and Accountability Act (HIPAA). The client asks the nurse what HIPAA covers. Which of the following most accurately describes what HIPAA covers?
The confidentiality of electronic and printed health information All documented information in the client record, whether electronic or printed, should be kept confidential. Most agencies require nurses to complete the HIPAA training to ensure that the use, disclosure of, and requests for protected information are applied only to intended purposes and kept to a minimum, thus preserving confidentiality.
To make a legal entry into the medical record, the nurse must document what?
Time of the assessment The nurse must record normal assessment data, abnormal assessment data, and the time of the assessment. The nurse does not have to document laboratory tests ordered, the attending physician, or the nature of the assessment.
After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?
To communicate effectively with other health care team members The primary reason for documentation of assessment data is to promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care. Although documentation may protect a practice from liability, help avoid penalties, and aid the nurse's recall of client information, none of these is the primary reason for documentation.
A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
To provide a record of the actual events The client record serves as a legal document recording the client's health status and any care the client receives. While all answers are correct, the best answer is providing a record of the actual events
When a client reports never having had surgery, yet physical examination reveals a 10-cm abdominal scar, the nurse needs to:
Validate the data Discrepancies between observed findings and the client's report necessitate validation. It would be inappropriate and unnecessary to label the client unreliable, confront the client, or seek an alternative source.
The nurse would perform handoff report for which situation? Select all that apply.
When leaving for lunch When sending the client for an endoscopy At shift change Upon transferring to ICU Handoff, or transfer of care of a client from one health care provider to another should occur when there is a transfer of responsibility for the care of the patient to another. Lunch breaks, transferring the client to ICU or procedural areas and at shift change all require a handoff. When the nurse is assessing other clients, the nurse retains responsibility for the client and no handoff is needed.
Examples of objective data include all the following except:
itchy skin Objective data are information obtained during the physical examination. They include all data gathered by inspection, palpation, percussion, and auscultation. Coughing is audible to the examiner, foul-smelling discharge can be smelled, and reddened skin can be noted on inspection. Itchy skin is a subjective report from the client experiencing it.
Initial assessment form
nursing admission on admission database
One disadvantage of the open-ended assessment form is that it
requires a lot of time to complete. Open-ended forms (traditional form) requires a lot of time to complete the database.
Validation of data
the process of confirming or verifying that the subjective and objective data you collected are reliable and accurate. Errors during assessment cause the nurse's judgment to be made on unreliable data, which results in diagnostic errors • A crucial element to the first step of the nursing process