Chapter 10: Documentation and Communication

The federally initiated goal of computer-based personal records would likely produce which of the following benefits? Select all that apply. A) Access to records outside of the patients home facility B) Increased accuracy of treatment for the patient outside their home facility C) Easier access to data for research D) Increased incidence of identity theft E) Greater accuracy and improved patient care

A) Access to records outside of the patients home facility B) Increased accuracy of treatment for the patient outside their home facility C) Easier access to data for research E) Greater accuracy and improved patient care

When the nurse recognizes that he has documented one patients assessment data on the wrong patients medical record, the nurse should A) Draw a single line through the error, and initial it B) Use a felt tip pen to cover the error C) Use white out to cover the error D) Replace the record, rewriting the error

A) Draw a single line through the error, and initial it

The patient record is utilized for many purposes. Which of following might be uses for the patient record? A) Education of student nurses B) Reimbursement for services C) Research D) Giving information over the phone when unidentified callers call the hospital unit E) Education for medical students

A) Education of student nurses B) Reimbursement for services C) Research E) Education for medical students

What organization audits charts regularly? A) Joint Commission on Accreditation of Healthcare Organizations B) National League for Nursing C) American Nurses Association D) Sigma Theta Tau International

A) Joint Commission on Accreditation of Healthcare Organizations

The nurse is caring for an elderly resident in a long-term care facility. The patient is crying and states, I dont want to live anymore. I am a burden on everyone. I dont feel like doing anything at all. I dont even want to get up today. Which of the following should the nurse record in his charting? Select all that apply. A) Patient is crying. B) Patient states, I dont want to live anymore. I am a burden of everyone. I dont feel like doing anything at all. I dont even want to get up today. C) Patient seems depressed. D) Patient is suicidal. E) Patient is in a bad mood.

A) Patient is crying. B) Patient states, I dont want to live anymore. I am a burden of everyone. I dont feel like doing anything at all. I dont even want to get up today.

How can a nurse obtain additional information about a patient? A) Read the patients history and assessment. B) Call the patients family. C) Ask the patients sister about the family history. D) Review nursing literature.

A) Read the patients history and assessment.

A nurse is working as a case manager, and in this role she audits charts. Audits of patient records are performed primarily for quality assurance and A) Reimbursement B) Staff development C) Research D) Change of mechanisms

A) Reimbursement

The nurse is interviewing a newly admitted patient. Quoting statements made by the patient will help in maintaining A) Subjectivity B) Objectivity C) Organization D) Reimbursement

A) Subjectivity

Which of the following should the nurse include in his/her charting? Select all that apply. A) The nursing assistant reports the patients breath smelled of alcohol. B) I feel something is going on she is not telling me. C) The patient was overheard telling his family about more bleeding than he has reported to his physician. D) The incision is oozing a small amount of red blood. E) The patients pupils are dilated.

A) The nursing assistant reports the patients breath smelled of alcohol. C) The patient was overheard telling his family about more bleeding than he has reported to his physician. D) The incision is oozing a small amount of red blood. E) The patients pupils are dilated.

A new graduate is working at her first job. Which of the following statements is most important for the new nurse to follow? A) Use abbreviations approved by the facility. B) Document lengthy entries using complete sentences. C) Use PIE charting even if it is not the institutions charting method. D) Only document changes in the patients status.

A) Use abbreviations approved by the facility.

9. Which of the following flow sheets provides the reader with information on an ongoing record of fluid loss? A) Vital sign sheet B) Intake and output sheet C) Critical care flow sheet D) Health assessment flow sheet

B) Intake and output sheet

A concise document that provides most of the patients nursing and medical information is a(n) A) Nursing care plan B) Kardex C) Past chart D) Office record

B) Kardex

Besides being an instrument of continuous patient care, the patients medical record also serves as a(an) A) Assessment tool B) Legal document C) Kardex D) Incident report

B) Legal document

A plan of care should be generated at admission and revised to reflect changes in the patients condition. 14. A patients record can be more accurate if the nurse A) Charts at least every 2 hours B) Uses point-of-care documentation C) Summarizes patient care at the end of the shift D) Delegates charting to the nurse assistant

B) Uses point-of-care documentation

The patient states, I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today. His arms are folded across his chest. His brow is furrowed and he refuses to allow his morning vital sign measurements. Which of the following should be included in the nurses charting? Select all that apply. A) Seems angry today B) Unhappy with his care C) Arms are folded across his chest and brow is furrowed D) States, I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today. E) Refuses to allow morning vital sign measurements

C) Arms are folded across his chest and brow is furrowed D) States, I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today. E) Refuses to allow morning vital sign measurements

What ensures continuity of care? A) Reassessment B) Critical thinking C) Communication D) Integration

C) Communication

The highest standard for maintaining a patients condition is A) Reporting B) Documentation C) Confidentiality D) Management

C) Confidentiality

1. Which of the following statements by the student nurse demonstrates understanding of the appropriate way to document an error in her charting? A) If I make an error, I can draw a red circle around it. B) If I make an error, I have to rewrite the entire entry. C) If I make an error, I draw a single line through it and put my initials by it. D) If I make an error, I place an X through it. E) If I make an error, I use white-out on it.

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

A nurse in a nursing home is writing a note on a resident that addresses the care the resident has received during the day and the residents response to care. What type of note does this represent? A) PIE note B) Flow sheet C) Narrative note D) SOAP note

C) Narrative note

The nurse is caring for a patient with uncontrolled hypertension. His blood pressure has remained controlled for the nurses shift. At two-hour intervals the blood pressure was checked by the nurse and found to be essentially the same. The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the patient has a stroke. Years later, the patient files a lawsuit blaming the hospital for his stroke. The nurse who was caring for the patient when his blood pressure was stable cannot recall the exact blood pressure she obtained, but remembers it was normal. Will this recollection suffice in court and why? A) Yes, the nurse remembers the pressure as normal during her shift and can swear to it during the deposition. B) No, but it will relieve the nurse of any wrongdoing. C) No, if the blood pressure measurement was not documented, it did not happen. D) Yes, the nurse was not on duty when the stroke occurred.

C) No, if the blood pressure measurement was not documented, it did not happen.

Which of the following principles should guide the nurses documentation of entries on the patients medical record? A) Nurses may not document for another health professional. B) Documentation does not include photographs. C) Precise measurements are preferred over approximations. D) Nurses should not refer to the names of physicians.

C) Precise measurements are preferred over approximations.

The sharing of information ab a patient is A) Communication B) Documentation C) Reporting D) Verification

C) Reporting

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic patient chart is that A) No other charting method is necessary. B) Access is open to anyone. C) Retrieval of information is more efficient. D) It is less costly to maintain.

C) Retrieval of information is more efficient.

4. Which of the following describe best practices for charting? Select all that apply. A) Use long narratives to be sure your documentation is understood B) Always use complete sentences C) Use only approved abbreviations D) Always use the patients name and words referring to the patient in each entry E) Use partial sentences and phrases

C) Use only approved abbreviations E) Use partial sentences and phrases

What dual purpose does an audit serve? A) Communication and evaluation B) Knowledge and quality C) Education and confidentiality D) Quality assurance and reimbursement

D) Quality assurance and reimbursement

During a patients hospitalization, he has developed shortness of breath, with edema. What action should the nurse take? A) Review the nursing care plan B) Implement changes in the current interventions C) Involve the family in changes D) Revise the plan of care

D) Revise the plan of care

Charting in which the nurse writes a progress note that relates to one health problem is a A) PIE note B) Flow sheet C) Narrative note D) SOAP note

D) SOAP note

How can the nurse researcher obtain information from a patient record? A) Audit discharge records B) Interview nursing staff C) Examine institutional procedures D) Study patient records

D) Study patient records

What activity in charting will assist most in the avoidance of errors? A) Objectivity B) Organization C) Legibility D) Timeliness

D) Timeliness