Chapter 19 - Documenting and Reporting

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate?

"Any information that can identify a person is considered a breach of client privacy."

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: The use of rationales is not commonly practiced in the clinical setting. The rationale is deleted to provide additional charting space in the computer system. Rationales are only important while the nurse is in training. Some facilities do not require them on their plans of care. Although not written, the nurse must know or question the rationale before performing an action.

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

Accurate documentation for a patient given Diovan, 10 mg, once daily is: "Diovan, 10 mg, Q.D."

FALSE

An example of a helpful and accurate nursing note is: "The patient appears to be resting more comfortably today than yesterday."

FALSE

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? Nurse's shift report Incident report Telemedicine report Transfer report

Incident report

Critical pathways or care maps, used in the case management model, specify the care plan that is linked to expected outcomes projected along a timeline.

TRUE

In most facilities, the only circumstance in which orders may be issued verbally is in a medical emergency.

TRUE

The patient record is the only permanent legal document that details the nurse's interactions with the patient.

TRUE

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

Use abbreviations approved by the facility.

Handoff

a nurse's report to another nurse or health care provider about a patient's status and progress

ISBAR communication

a process for effective hand-off communication among health care professionals about a patient's condition, standing for Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read back

read-back

a process in which a nurse or other health care provider repeats a verbal order back to a physician to ensure that it was correctly heard and interpreted

incident report

a report of any event that is not consistent with the routine operation of the health care facility that results in or has the potential to result in harm to a patient, employee, or visitor

progress notes

any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes

critical/collaborative pathway

case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions

discharge summary

description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals

occurrence charting

documentation when a patient fails to meet an expected outcome or a planned intervention is not implemented, including the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, when appropriate; typically used for variances that affect quality, cost, or length of stay

Computer-based records, or ____________ health records (EHRs), allow data to be distributed among many caregivers in a standardized format.

electronic

narrative notes

progress notes written by nurses in a source-oriented record

confer

to consult with someone to exchange ideas or to seek information, advice, or instructions

purposeful rounding

proactive, systematic, nurse-driven, evidence-based intervention that helps nurses anticipate and address patient needs

A _______-oriented patient record is one in which each health care group keeps data on its own separate form.

source

documentation

written, legal record of all pertinent interventions with the patient—assessments, diagnoses, plans, interventions, and evaluations

graphic record

form used to record specific patient variables

SOAP format

method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P)

consultation

process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution

bedside report

standardized, streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family

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 record

documentation system in which each health care group records data on its own separate form

Which is the proper way to document midnight in a client's record? 1200 2401 0000 1201

0000

In SBAR, what does R stand for?

Recommendations

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

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate? "Clipboards with client data should not leave the unit." "You can get an electronic printout of client lab data to take with you." "Be sure to write down specific information for your clinical paperwork." "Be sure to put the client's name and room number on all paperwork."

"Clipboards with client data should not leave the unit."

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? Write the order in the client's record. Call the pharmacy to have the order entered in the electronic record. Add the new order to the medication administration record. Inform the health care provider that a written order is needed.

Inform the health care provider that a written order is needed.

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

Reporting

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a client whose rehabilitation potential is not good a client whose status is stabilized a client who is not making progress in expected outcomes of care a client who is homebound and needs skilled nursing care

a client who is homebound and needs skilled nursing care

Outcome and Assessment Information Set (OASIS)

assessment instrument representing core items of a comprehensive assessment for adult nonmaternity home health care patients that forms the basis for measuring patient outcomes for the purpose of improving the quality of care provided

Quality process review recognizes that _____________ is the primary source of evidence used to continuously measure performance outcomes against predetermined standards.

documentation

Besides being an instrument of continuous client care, the client's health care record also serves as a(an): Kardex. assessment tool. legal document. incident report.

legal document.

Which abbreviation is correct for use in documentation? PO Sub q Per os BT

PO

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 is coughing and experiencing severe heartburn in the morning. The client has symptoms in the morning associated with a heart attack. The client reports waking up this morning with a severe headache. The client has a history of severe complaints in the morning.

The client reports waking up this morning with a severe headache.

patient record

a compilation of a patient's health information; the patient record is the only permanent legal document that details the nurse's interactions with the patient

Health Information Exchange (HIE)

an electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient's vital medical information

Change of shift report

communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped

Charting by ____________ is a shorthand documentation method in which only deviations from well-defined standards of practice are documented in narrative notes.

exception

The __________________record is 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.

graphic

flow sheet

graphic record of abbreviated aspects of the patient's condition (e.g., vital signs, routine aspects of care)

referral

process of sending or guiding someone to another source for assistance

variance report

tool used by health care facilities to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor; also called an incident report or occurrence report

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse? "Let me open up the computer access so that you can see what information is of interest to you." "You may not understand all of the information and it will confuse you so I will help you decipher it all." "The hospital owns your records and does not have to allow you access while you are a client here." "I will have to review the policy that determines what procedure is in place for client access."

"I will have to review the policy that determines what procedure is in place for client access."

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 appears comfortable and is resting adequately and appears to not be in acute distress. The client reports that on a scale of 0 to 10, the current pain is a 3. The client is receiving sufficient relief from pain medication, stating no pain in either knee. The client appears to have a low tolerance for pain and frequently reports intense pain.

The client reports that on a scale of 0 to 10, the current pain is a 3.

Electronic Health Record (EHR)

digital version of a patient's chart that may contain the patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results

variance charting

documentation method in case management when a patient fails to meet an expected outcome or when a planned intervention is not implemented that records unexpected events, the cause for the event, actions taken in response to the event, and discharge planning when appropriate; typically used for variances that affect quality, coast, or length of stay; also called occurrence charting

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

The nurse is caring for a client who is prescribed a pain medication by mouth every 4 to 6 hours. When assessing pain status, the client states not wanting to take any medication right now. Which principle should the nurse consider when documenting interventions regarding medication administration for this client? The client's pain should be documented on a scale of 0 to 10 when documenting the administration of pain medication. Steps taken to encourage the client to comply should be documented along with assessment findings. Medication should be documented along with the time and the amount given or not given each time medication is scheduled to be administered. Medication that is not administered should be documented along with the reason.

Medication that is not administered should be documented along with the reason.

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

personal health record (PHR)

information sheets that contain the individual's medical history, including diagnoses, symptoms, and medications

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 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 problem list plan of care data base

progress notes

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? "I am calling about the patient in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin." "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." "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."

"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."

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply. "I will stay logged in on the computer until the end of my shift." "I will use only agency-approved abbreviations." "I will write, print, or type information legibly." "I will draw a straight line through any blank space." "I will elaborate on the details on my entry in the clients' records."

"I will write, print, or type information legibly." "I will use only agency-approved abbreviations." "I will draw a straight line through any blank space."

Minimum Data Set (MDS)

a standard established by health care institutions that specifies the information that must be collected from every patient