Chapter 19: Documenting and Reporting

A nurse is documenting the effectiveness of a client's pain management on the client record. Which documentation is written correctly? A. Mr. Gray reports that on a scale of 0 to 10, the pain he is experiencing is a 3. B. Mr. Gray appears to have a low tolerance for pain and frequently reposts intense pain C. Mr. Gray is receiving sufficient relief from pain medication D. Mr. Gray appears comfortable and is resting adequately

A.

Who created the code of ethics for nursing?

American Nurses Association (ANA)

When documenting information in a client's medical record, what should the nurse do consistently for each entry? A. report each observation to the physician B. sign each entry by name and title C. obtain a signature from the physician D. provide a day of the week on the entry

B.

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 refuses. The nurse's refusal is based on the understanding that which of the following people would be entitled to access of the client's records? A. health care professionals of the facility B. close friends of the client C. those directly involved in the pt's care D. any family member of the pt

C.

Which of the following flow sheets provides the health care provider with information on an ongoing record of fluid loss? A. Vital signs graphic sheet B. Critical care flow sheet C. Intake and output graphic sheet D. Health assessment flow sheet

C.

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which clinical situation? A. When reporting to a pt's family member or significant other B. When documenting the care that was provided to a pt whose condition recently deteriorated C. When transferring a pt from the ER to the acute care unit D. When preparing to discharge the pt home

C. Rationale: ISBAR should be used for interdisciplinary communication

It is acceptable for the nurse to accept a verbal order from the physician in which situation? A. immediately prior to discharge B. upon admission of the pt to the unit C. prior to the pt leaving the floor for therapy D. during a medical emergency

D.

How can we give report of pt care?

FTF, phone, written, audiotaped, computer

True or false? Since the RN delegated a task to an assistive personnel, they are no longer responsible if something goes wrong.

False; it is the RN's responsibility so it can come back on them if something goes wrong

ISBAR

I- identify/introduction S- situation B- background A- assessment R- recommendation

Hand-off communication

ISBAR is recommended to communicate with other disciplines to organize the info so they can have a better understanding

Guidelines for nursing student's care plans:

NEVER put patient identifiers or their first and last name on our care plans

Can a RN delegate a full assessment?

No, it must be completed by the RN

Narrative notes

Progress notes written in a source oriented record that address routine care, normal findings, and patient problems identified in the plan of care.

Which documentation cannot be delegated by the RN?

RN assessment, Foley catheters or IV's

SOAP charting

S- subjective (how the pt says they feel; ex: my leg hurts) O- objective (factual information; ex: vitals, respirations, labs so we can verify what the pt says) A- assessment P- plan (what do you plan do to based on the information you have gathered)

Why do we never skip lines while charting?

Someone could add something to the chart (CYA for legal reasons)

Discharge and transfer summary

Summarizes reason for treatment, significant findings, procedures performed and treatment rendered, patient's condition on discharge or transfer, and any specific pertinent instructions given to the patient and family (like education)

HIPAA

a pt's health information is considered confidential and the pt has the right to see their record and can update anything and choose who can be told about their illness/treatment

Home health/long term care documentation

always document whether or not they will need home or long-term care

Initial nursing assessment

baseline for later comparison including initial assessment and history

Focused charting

brings focus of charting back to the pt's concerns (reduces the time charting and minimizes excess information)

Format of charting

can be paper and pen (if so only use dark ink), use standard terminology, never skip any lines

Flow sheets

document where vitals are recorded (INO, RR, BP, HR, temp)

Case management model

focus is on quality, cost effective care delivered within a limited time frame (has a lot to do with reimbursement)

Problem oriented records

focuses on what is going on with the pt (all disciplines record info on the same forms and the team works closely together)

Why is charting important for reimbursement purposes?

it is used by insurance companies to decide about payment and make sure treatments were medically necessary; insurance companies can deny reimbursement if something was done incorrectly or something unintended happens

Why is research essential in the nursing profession?

it promotes evidence based practice and helps provide quality healthcare

Confidentiality in charting

keep information confidential including their name, date of birth, age, and demographics

Standalone personal health records

patients fill in information from their own records and the information is stored on the pt's computer or on the internet

PIE charting

problem, intervention, evaluation

SOAP charting is included in....

problem-oriented records

Which type of record is a master list of problems involving all disciplines caring for a pt?

problem-oriented records

What should the nurse do when they receive a verbal order?

repeat the order back to them to make sure it was intercepted correctly

Patients have the right to:

see and copy their health records, update them, get a list of disclosures, request restriction of certain disclosures, and choose how to receive their health information

Source oriented records

type of charting where you have a chart divided into sections and each discipline has a section they can chart under (PAPER CHART)

Which documentation can be delegated by the RN?

vitals, input and output, and accuchecks

Progress note

way of documenting pt's daily progress of the identified problems

Graphic records

way of documenting routine pt care; can be an easy way to see trends with vitals like BP, temp, pulse, INO, and bowel

Does breaking HIPAA have legal ramifications?

yes; you can be fined and possibly face jail time based on the severity of the breach

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal handoff report? A. current pt assessment B. pt's family members C. pt's admission number D. pt's intake for previous meals

A.

A nursing student is preparing a presentation on client records and documentation. What information should the student include in the presentation? A. communication is the primary purpose of client records. B. nurses should not document progress notes on a pt's record C. pt's should keep the original record at home in a fire proof safe D. physicians will not review nurse's documentation in the pt's record

A.

Anew graduate is working at a first job. Which statement is most important for the new nurse to follow? A. Use abbreviations approved by the facility. B. Use PIE charting even if it is not the institution's charting method. C. Only document changes in the client's status. D. Document lengthy entries using complete sentences.

A.

Besides using the medical records, which form of communication should the nurse use to provide client details to the health care team coming on duty in the next shift? A. change of shift reports B. team conferences C. telephone calls D. client assignments

A.

When maintaining medical 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 legal defensible charting? A. ensure the pt's name appears on all pages B. record all facts and subjective interpretations C. use abbreviations wherever possible D. leave spaces between entries and signature

A. Rationale: nurse should ensure that client's name appear on all pages to ensure legally defensible charting. Nurse should record all facts but not any subjective interpretations, to ensure that document is legal evidence

A hospital is charting 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 nurse document the significant finding as a narrative note, in a shorthand method using well defined standards of practice. Which of the following best defines this type of charting? A. charting by exception (CBE) B. variance charting C. FOCUS charting D. Problem, Intervention, Evaluation (PIE) charting

A. Rationale: this is a shorthand method that only includes significant findings (not routine care like vitals)

The nurse mistakenly documented one client's assessment data on another client's health care record. What action should the nurse take? A. Use a dark colored felt tip pen and black out the error B. Draw a single line through the error, initial it, and write the correct entry C. Use correction fluid to cover the error and write the correct entry over it D. Replace the record sheet and write the correct entry on the new sheet

B.

When taking a telephone order from a physician, the nurse verifies that she understands the order by: A. asking them to summarize the orders given B. repeating the order back to them C. confirming the order with the nurse manager D. faxing the written order to the physician's office

B.

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 her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? A. following up on an indecent with other members of the care team B. identifying risks and ensuring future safety for pts C. gauging the nurse's professional performance over time D. protecting the nurse and hospital from litigation

B. Rationale: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: A. using only abbreviations whose meaning is self evident to an educated health professional B. limiting abbreviations to those approved for use by the institution C. using only those abbreviations that are defined in full at another location in the pt's chart D. ensuring that abbreviations are understandable to pt's who may seek access to their health records

B. Rationale: 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 client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.

Which example may illustrate a breach of confidentiality and security of patient information? A. The nurse informs a colleague that she should not be discussing pt information in the hospital cafeteria. B. The nurse provides information over the phone to the patient's family member who lives in a neighboring state. C. The nurse assesses pt information on the computer at the nurse's station, and logs off before answering a call light D. The nurse provides info to a professional caregiver involved in the care of the pt

B. Rationale: providing info over the phone without knowing if the pt wants the family member to know the info is a breach of confidentiality

The health care provider approaches the nurse caring for the client in room 25 and states, "The client is a friend of mine. What treatment is being given?" What response by the nurse is most appropriate? A. Open the health record for the doctor to review the treatment ordered B. Inform the health provider of a busy schedule preventing answering any questions at this time C. Inform the health care provider that client permission is needed to release any information. D. Tell the healthcare provider caring for the pt to obtain any information

C.

A healthcare provider suggests that the nurse use the computer terminal that is available at the point of care or at the client's bedside. What is the probable reason for the physician's suggestion? A. it solves the space constraint of the hospital B. the pt needs to check the entry as well C. there are limited computer modules available D. it keeps the nurse close to the source of data

D.

A nursing student is attending a clinical rotation in a labor/deliver/postpartum unit and is able to see a vaginal delivery for the first time. The student takes a picture of the newborn and posts it on a social mediat website. What action may occur related to this privacy violation? A. no action will be taken as long as the parents don't find out B. there will be no repercussions if the student takes the picture down from the social media page C. the student will never be eligible for entry into a nursing program or be able to take the NCLEX D. The student may be dismissed from the nursing program as well as fined for a HIPAA violation.

D.

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 style of documentation is the nursing implementing? A. PIE charting B. FOCUS charting C. narrative charting D. SOAP charting

D.

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A. a pt wishes to appeal her insurance company's refusal to reimburse for a diagnostic test B. a pt who resides in Indiana has required hospitalization during a vacation in Hawaii C. a pt has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer D. a pt has asked the nurse if he can read what the physician wrote in his chart

D.

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? A. Problem, intervention, and evaluation note B. FOCUS data, action, and response note C. Narrative notes D. Charting by exception

D. Rationale: The team would most likely suggest the use of charting by exception, which is an abbreviated form of documentation. Narrative notes are time-consuming to write and require much reading to learn about a specific problem. The problem, intervention, and evaluation note system simplifies documentation by incorporating the plan of care into the progress notes. The FOCUS system of documentation organizes entries by data, action, and response. This system is broader in its view because a FOCUS can be a problem area, but does not need to be.

Is it appropriate to scribble out information on a patient's medical record?

No, we need to mark a line through the statement and initial it

Are nursing students allowed to take patient info out of the hospital even if a nurse has printed it and given it to them?

No; this would be a violation of HIPAA

Advantages of electronic health records (EHRS)

all of the pt information is in the same place and everyone on their care team has access to it and we can chart at the bedside

Health information exchange (HIE)

allows multiple healthcare providers and patients to access and share medical information electronically (improves speed, quality, safety, and cost of pt care)

How do we make corrections to the patient record?

cross through the statement with only one line and sign initials

Care planning

deciding what problems the patient has and work on interventions and evaluate at the end of the stay to see if we addressed all of the concerns; big piece of what nurses do

Disadvantages of charting by exception

difficult to prove high quality, safe care was given (because things don't get documented so there is no proof) the routine care is not documented

When can someone's PHI be disclosed?

for public health activities (disease outbreaks), legal and judicial processes (release info of abuse with a proper subpoena), and if they are deceased we can give info to the funeral home or the morgue

Nursing care rounds are used to...

gather info and make sure we are following through and evaluating things that are being done for the pt

Aim of documentation

have complete, accurate, concise, and organized data communicated in a timely matter to remain confidential and correlated to facilitate care to the patient.

Where should patient information be discussed?

in pre and post clinical conferences only behind closed doors

Benefits of charting by exception

less time spend documenting, emphasis on significant data, greater interdiscipinlary communication, and better tracking of pt responses

Tethered/connected personal health records

linked to a specific health care organizations electronic health record system or to a health plan's information system

Can an RN delegate medication administration?

no

Content of effective documentation

only use facts, not opinions and avoid using works like good, best, and normal

Charting by exception

shorthand documentation were only the significant findings or "exceptions" are included in the narrative notes

Types of personal health records

standalone and tethered/connected

Benefit of health information exchange

stimulates consumer education and pt's involvement in their own healthcare

Which important piece of information is included in the source oriented record?

the narrative note

Disadvantages of source oriented records or narrative notes

they are not in chronological order so you don't know the order that care occurred

Advantages of source oriented records

you can easily find information you need and it contains everything needed for legal reasons