Chapter 19 - Documenting and Reporting
peer review
evaluation at the closest point to the patient and an ongoing tool to use for professional growth
structure evaluation
focuses on the environment in which care is provided; also known as an audit
nursing-sensitive quality indicators
indicators that capture care or its outcomes most affected by nursing care
What dual purpose does an audit serve?
quality assurance and reimbursement
A nurse is preparing a seminar on the uses of documentation in client records. Which topics should the nurse include in the seminar? Select all that apply.
quality improvement research decision analysis financial reimbursement
RAI
resident assessment instrument
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 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."
Elements of Documenting
* Content * Timing * Format * Accountability * Confidentiality
Four Basic Components of RAI (Resident Assessment Tool)
* Minimum data set * Triggers * Resident assessment protocols * Utilization guidelines * used for reimbursement of medicare
conferring about care
Consultations and referrals Nursing and interdisciplinary team care conferences Nursing care rounds
point of care documentation (POC)
Documentation that takes place as care occurs
Hand-off Communication/ISBARR
Identity/Introduction Situation Background Assessment Recommendation Read back of orders/response
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.
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?
It provides quick access to abnormal findings.
Which abbreviation is correct for use in documentation?
PO
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?
Problem-oriented method
Patient Rights
See and copy their health record Update their health record Get a list of disclosures Request a restriction on certain uses or disclosures Choose how to receive health information
case management model
collaboration between disciplines to create a multidisciplinary care plan for each client
Methods of Documentation
Source-oriented records Problem-oriented medical records PIE charting (problem, intervention, evaluation) Focus charting Charting by exception Case management model Computerized documentation/Electronic health records (EHRs)
Which organization audits charts regularly?
The Joint Commission
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 reports waking up this morning with a severe headache.
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
Focus charting
a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format
Source-Oriented Medical Record (SOMR)
a type of patient chart record keeping that includes separate sections for different sources of patient information, such as laboratory reports, pathology reports, and progress notes.
A nurse is transfusing multiple units of packed red blood cells (PRBCs). 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 think the client would benefit from intravenous furosemide."
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."
Which documentation tool will the nurse use to record the client's vital signs every 4 hours?
A flow sheet
problem list
A list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution
A nurse manager is conducting an in-service education program about client records and documentation for a group of nurses working on the medical-surgical unit. After teaching the group about this topic, the nurse determines that the teaching was successful when the group identifies which aspect as the primary purpose of client records?
Communication
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.
To improve communication within the health care system, tools were created to standardize the process and assist with clarity and conciseness. SBAR is one such tool. In this tool, what does R stand for?
Recommendations
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?
Translators may need additional explanations of medical terms.
Evaluating
measurement of the extent to which the patient has achieved the goals specified in the plan of care; factors that positively or negatively influence goal achievement are identified, and the plan of care is terminated or revised
evidence-based practice
nursing care provided that is supported by sound scientific rationale
SOAP
subjective, objective, assessment, plan
The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?
subjectivity
care plans
written plans developed by the nurse that outline the steps taken by the staff to reach the goals or outcomes set
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."
Potential breaches in patient confidentiality
* Displaying information on a public screen * Sending confidential e-mail messages via public networks * Sharing printers among units with differing functions * Discarding copies of patient information in trash cans * Holding conversations that can be overheard * Faxing confidential information to unauthorized persons * Sending confidential messages overheard on pagers
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?
Ask the client if information can be given to the parent.
The nurse hears an unlicensed assitive personel (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.
Quality Improvement (QI)
the commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes—also known as continuous quality improvement (CQI) or total quality management (TQM)
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?
those directly involved in the client's care
The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?
urine output 100 ml
A nurse is taking care of a client post knee surgery. The nurse follows a clinical pathway that guides the care of this client after this specific procedure. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What does the nurse identify this event as?
variance
Purpose of recording data
Facilitate patient care Serve as a financial and legal record Help in clinical research Support decision analysis
process evaluation
evaluation focusing on the nature and sequence of activities carried out by nurses implementing the nursing process
retrospective evaluation
evaluation of nursing care and patient outcomes after the patient has been discharged using postdischarge questionnaires, patient interviews, or chart review to collect data
standards
rules or guidelines that allow nurses to carry out professional roles, serving as protection for the nurse, the patient, and the institution where health care is given
criteria
specified behavior; for example, the measurable criteria in a patient goal specifies how the patient must perform the desired behavior
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.
Charting by exception
shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes
evaluative statement
a judgment summarizing the nurse's findings after data have been collected and interpreted to determine patient outcome achievement
Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records?
"The clients' medical records are an obstruction to research and education."
quality assurance program
ongoing evaluation program designed and implemented to secure the excellence of health care; may involve an assessment of structure, process, and outcome standards
Benefits of a health information exchange
- provides a vehicle for improving quality and safety of patient care - provides a basic level of interoperability among EHRs maintained by individual physicians and organizations - stimulates consumer education and patients' involvement in their own health care - helps public health officials meet their commitment to the community - creates a potential loop for feedback between health-related research and actual practice - facilitates efficient deployment of emerging technology and health care services - provides the backbone of technical infrastructure for leverage by national and state-level initiatives
Purposes of Patient Records
-Communication -Diagnostic and therapeutic orders -care planning -legal -historical documentation -research -education -credentialing -reimbursement -quality improvement
The nurse in making an entry on the client's chart: "Medicated with meperidine 50 mg at midnight." How would the nurse document the entry using military time?
0000
Two types of Personal health records (PHRs)
1) Standalone personal health records 2) Tethered/connected personal health records
Types of flow sheet
Graphic record 24-hour fluid balance record Medication record 24-hour patient care records and acuity charting forms
Which statement is not true regarding a medication administration record (MAR)?
If the client declines the dose you do not have to document this on the MAR.
The health care provider tells the client, "You are experiencing an MI," and leaves the room. The client asks the nurse what an MI stands for. What response by the nurse is most accurate?
Myocardial Infarction
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.
progress notes
any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes
SOAP format
subjective, objective, assessment, plan
A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?
"According to HIPAA legislation, you have a right to request changes to inaccurate information."
The nurse recognizes that documentation of one client's assessment data is on another client's health care record. Which action should the nurse take?
Draw a single line through the error and initial it.
Policy for Receiving Verbal Orders in an Emergency
Record the orders in patient's medical record. Read back the order to verify accuracy. Date and note the time orders were issued in emergency. Record verbal order and name of the physician issuing the order, followed by nurse's name and initials.
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.
problem-oriented medical records
database, problem list, treatment plan, progress notes
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 giving the change-of-shift report on a client who has just returned from surgery. What client information should the nurse include in the report? Select all that apply.
name of the client intake and output prior to surgery client discharge teaching needs current vital signs
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?
progress notes
Charting by exception (CBE)
shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes
What situation would permit the nurse to disclose information without the client's approval?
the nurse suspecting that a client is being abused or neglected
The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?
"Will you prescribe a CBC to check the WBCs and a culture?"
PIE charting
documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P)-intervention (I)-evaluation (E) format, and evaluated each shift
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."
Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.
*obscuring identifiable names of clients and private information about clients on clipboards *placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public *keeping record of people who have access to clients' records
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
Computerized Documentation
- aka EHR (electronic health records) - used to manage the huge volume of info required in contemporary healthcare - advantages: can facilitate a focus on client outcomes, allows nurse to use their time more efficiently, links various sources of client info, and more - disadvantages: client's privacy may be infringed on if security measures are not used, expensive, extended training periods for healthcare professionals
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
Formats for nursing documentation
Initial nursing assessment Care plan; patient care summary Critical collaborative pathways Progress notes Flow sheets and graphic records Medication record Acuity record Discharge and transfer summary Long-term care documentation
The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?
Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.
Which is not a purpose of the client care record?
contract
The parents of a hospitalized child 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."
graphic record
a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics
A nursing instructor is discussing a nursing student's social media post about an interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is most appropriate?
"Any information that can identify a person is considered a breach of client privacy."
A nurse helps a client who has cystic fibrosis prepare a stand-alone personal health record. Which statement by the nurse best explains this type of information?
"You can fill in information from your own records and store it on your computer or the Internet."
A group of newly hired nurses is being oriented to the ambulatory care center where they will be working. The center follows the case management model. During the orientation, the nurse manager tells the group that the center uses collaborative pathways for documentation. One of the nurses in the group asks, "What are these?" Which response by the nurse manager would be appropriate?
"You might hear them called critical pathways or care maps."
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.
*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.
Benefits of Nursing Informatics
- Increase in the accuracy and completeness of nursing documentation - Improvement in the nurse's workflow and an elimination of redundant documentation - Automation of the collection and reuse of nursing data - Facilitation of the analysis of clinical data
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?
Attach a copy of the incident report to the chart.
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. Which information would the nurse include for the "S" component?
Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."
Medicare Requirements for Home Health Care
Patient is homebound and still needs skilled nursing care. Rehabilitation potential is good (or patient is dying). The patient's status is not stabilized. The patient is making progress in expected outcomes of care.
Which principle should guide the nurse's documentation of entries on the client's health care record?
Precise measurements should be used rather than approximations.
A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse best reflects the effectiveness of the pain medication?
Rates pain 8/10, states nauseated for last 30 minutes.
Policy for Physician Review of Verbal Orders
Review orders for accuracy. Sign orders with name, title, and pager number. Date and note time orders signed.
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. 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 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. 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
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?
Use minimum disclosure policy to release the information.
Besides being an instrument of continuous client care, the client's health care record also serves as a(an):
legal document
What ensures continuity of care?
communication
According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?
documentation
source-oriented record
documentation system in which each health care group records data on its own separate form
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
To which Health Insurance Portability and Accountability Act regulation should the nurse adhere when safeguarding clients' written, spoken, and electronic information?
submitting a written notice to all clients identifying the uses and disclosures of their health information
Which documentation by the nurse best supports the PIE charting system?
vomiting 250 mL undigested food, antiemetic given, no further vomiting
Change of Shift/Hand-off Reports
-Basic identifying information about each patient: name, room number, bed designation, diagnosis, and attending and consulting physicians -Current appraisal of each patient's health status -Current orders (especially any newly changed orders) -Abnormal occurrences during your shift -Any unfilled orders that need to be continued onto the next shift -Patient/family questions, concerns, needs -Reports on transfers/discharges
Telephone/Telemedicine Reports
-Identify yourself and the patient, and state your relationship to the patient. -Report concisely and accurately the change in the patient's condition that is of concern and what has already been done in response to this condition. -Report the patient's current vital signs and clinical manifestations. -Have the patient's record at hand to make knowledgeable responses to any physician's inquiries. -Concisely record time and date of the call, what was communicated, and physician's response.
A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?
Accurately documenting client care on the client record
What is confidential?
All information about patients written on paper, spoken aloud, saved on computer - Name, address, phone, fax, social security - Reason person is sick - Treatments patient receives - Information about past health conditions
Which note includes all elements of a SOAP note?
Client reports nausea, one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. BP 130/85, HR 92. Nausea and vomiting of unknown etiology. Will give an antiemetic, will reassess within 1 hour for effectiveness.
When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legally defensible charting?
Ensure that the client's name appears on all pages.
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
Duties of RN Receiving Telephone Orders
Record the orders in patient's medical record. Read orders back to practitioner to verify accuracy. Date and note the time orders were issued. Record telephone orders, and full name and title of physician or nurse practitioner who issued orders. Sign the orders with name and title.
National Database of Nursing Quality Indicators (NDNQI)
ANA-funded database of nursing-sensitive quality indicators aimed at promoting and facilitating the standardization of information submitted by hospitals across the United States on nursing quality and patient outcomes
A nurse documents hypertension in a woman who is 5 months pregnant and then writes a narrative describing the situation. This type of abnormal status can be seen immediately with narrative easily retrieved in what documentation format?
Charting by exception
Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edmatous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"?
FOCUS charting
The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?
Reporting
A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment?
The lower extremities
performance improvement
commitment to healthier patients, quality care, reduced costs, and making a difference; accomplished by discovering a problem, planning a strategy, implementing a change, and assessing the change to see if the goal is met
problem-oriented medical record (POMR)
documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes
outcome evaluation
evaluation that focuses on measurable changes in the health status of the patient or the end results of nursing care
Which nursing assessments should the nurse take into consideration before making an entry into a client's record? Select all that apply.
reviewing the agency's list of approved abbreviations locating clients' files within an electronic recording system identifying the paper form appropriate to be used for documenting
Flow charts
show trends in vital signs, blood glucose levels, pain level, and other frequent assessments
concurrent evaluation
the evaluation of nursing care and patient outcomes while the patient is receiving care, conducted by using direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met
