Chapter 19: Documenting & Reporting

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data.

What dual purpose does an audit serve?

quality assurance and reimbursement

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and:

reimbursement.

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

urine output 100 ml

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."

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

"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."

A nurse is transfusing multiple units of packed red blood cells. 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 parents of a hospitalized 10-year-old 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."

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse?

"Legal policy requires nursing practice to be permanently integrated into the client record."

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."

Which statement by the nurse is the best example of an internal communication strategy the nurse should use to discuss the use of new equipment, client care problems, and change in policies?

"We will be having a team conference to discuss concerns that clients' relatives have raised."

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

1 Unit of glucose

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:

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

Which is the primary purpose of client records?

Communication

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation

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

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions

Which abbreviation is correct for use in documentation?

PO

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.

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?

Remind the UAP about the client's right to privacy.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting

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

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

Which organization audits charts regularly?

The Joint Commission

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider?

The nurse can accept verbal orders to provide immediate care and record once the client is stable.

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which information?

The physician's assessment and treatment

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them.

"I don't feel well. I've been urinating often, and it burns when I urinate." Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. Fever, possible urinary tract infection Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

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

A client's record can be more accurate if the nurse:

uses point-of-care documentation

Which note includes all elements of a SOAP note?

Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

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.

During hospitalization, the client has developed shortness of breath with edema. What action should the nurse take?

Revise the plan of care.

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 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."

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."

A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift?

"The client had a good deal of anxiety last night and requested to be turned and repositioned frequently."

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 complete blood count to check the white blood cell count and a culture?"

The nurse is tasked to organize weekly care plan conferences with other health care team members. Which would be appropriate items to include in this meeting? Select all that apply.

A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made A conversation addressing the need for durable medical equipment when the client goes home A discussion of the meal plan for a client with diabetes A review of a client's current progress in the plan of care

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 part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest?

charting by exception

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

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.

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

subjectivity

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."

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."

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."

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as?

A variance

A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines?

Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth

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.

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. S: The nurse handling the transfer describes the client situation to the new nurse.

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. How would the nurse document the "S" information?

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

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.

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation?

Source-oriented

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

Which actions should the nurse take before making an entry in a client's record? Select all that apply.

Reviewing the agency's list of approved abbreviations Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting

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.

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment?

The lower extremities

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.

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.

Which documentation by the nurse best supports the PIE charting system?

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?

Write a narrative note in the designated nursing section.

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

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

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

Which are appropriate actions for protecting clients' identities? Select all that apply.

Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.