Chapter 19: Documenting and Reporting

read-back

when the recipient reads back the message as he or she heard and interpreted it

discharge summary

written when a patient is discharged from care to transferred from one unit, institution, or facility to another and should be written that concisely summarizes the reason for treatment, significant findings, the procedures performed and treatment rendered, the patient's condition and other instructions.

confer

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

PIE charting

unique in that it does not develop a separate care plan. the care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified)

WHat is the primary purpose of an incident report? A.) means of identifying risks B.) basis for staff evaluation C.) basis for disciplinary action D.) format for audio-taped report

A.) Means of identifying risks

A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client confidentiality? A) Writing the client's name on the student care plan B) Providing the instructor with plans for care C) Discussing the medications with a unit nurse D) Providing information to the physician about laboratory data

A.) writing the client's name on the student care plan

A nurse is documenting information about a client in a long term care facility. What is used Medicare-certified facility as a comprehensive assessment and as the foundation for the resident assessment instrument (RAI)? A.) pie system B.) minimum data set C.) OASIS D.) charting by exception

Minimum data set

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

Narrative note

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? A) Narrative notes B) SOAP notes C) Focus charting D) Charting by exception

Narrative notes

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? A) "Client complaining of abdominal pain rated at 8/10." B) "Client is guarding her abdomen and occasionally moaning." C) "Client has a history of recent abdominal pain." D) "2 mg Dilaudid PO administered with good effect"

"Client complaining of abdominal pain rated at 8/10."

A nurse is documenting the intensity of a client's pain. What would be the most accurate entry? A) "Client complaining of severe pain." B) "Client appears to be in a lot of pain and is crying." C) "Client states has pain; walking in hall with ease." D) "Client states pain is a 9 on a scale of 1 to 10."

"Client states pain is a 9 on a scale of 1 to 10."

Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry? A) Alice J, RN B) A. Jones, RN C) Alice Jones D) AJRN

A. Jones, RN

A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse? A) "I am sorry that you had to suffer this way. The nurse on night duty should be fired." B) "It's hard to be in bed and ask for help. You ring for a nurse who never seems to help." C) "You seem to be impatient. The nurses work very hard and they do whatever they can." D) "I can see that you are angry. What the nurse did is wrong, and it won't happen again."

"It's hard to be in bed and ask for help. You ring for a nurse who never seems to help."

Which of the following abbreviations is on the list of the Joint Commission do not use abbreviations? Select all that apply. A) U (unit) B) QD (daily) C) NPO (nothing per os) D) mL (milliliters) E) > (greater than)

A )U (unit) B) QD (daily) E) > (greater than)

Which of the following are examples of breaches of client confidentiality? Select all that apply. A) A nurse discusses a client with a coworker in the elevator. B) A nurse shares her computer password with a relative of a client. C) A nurse checks the medical record of a client to see who should be called in an emergency. D) A nurse updates the employer of a client regarding the client's return to work. E) A nurse uses a computer to document a client's response to pain medication.

A) A nurse discusses a client with a coworker in the elevator. B) A nurse shares her computer password with a relative of a client. D) A nurse updates the employer of a client regarding the client's return to work

Which of the following are examples of incidental disclosures of client health information that are permitted? Select all that apply. A) A nurse working in a physician's office puts out a sign-in sheet for incoming clients. B) Two nurses are overheard talking about a client through the door of an empty client room. C) A nurse places a client chart in a holder on the examining room door with the name facing out. D) A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms. E) A nurse calls out the name of a client who is seated in the waiting room.

A) A nurse working in a physician's office puts out a sign-in sheet for incoming clients. B) Two nurses are overheard talking about a client through the door of an empty client room. E) A nurse calls out the name of a client who is seated in the waiting room.

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as ... A) Avelox (moxifloxacin) 400 mg daily B) Avelox (moxifloxacin) 400 mg Q.D. C) Avelox (moxifloxacin) 400 mg qd D) Avelox (moxifloxacin) 400 mg OD

Avelox (moxifloxacin) 400 mg daily

In which of the following cases should a progress note be written? Select all that apply. A) For any nurse-client interaction B) When admitting a client C) When receiving a client postoperatively D) When assisting a client with ADLs E) When a procedure is performed

B) When admitting a client C) When receiving a client postoperatively E) When a procedure is performed

Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse? A.) problem-oriented medical record B.) charting by exception C.) pie charting system D.) focus charting

B.) Charting by exception

A physician's order reads "up ad lib." What does this mean in terms of client activity? A) May walk twice a day B) May be up as desired C) May only go to the bathroom D) Must remain on bed rest

B.) may be up as desired

A nurse organizes client data using the SOAP format. Which of the following would be recorded under "S" of this acronym? A) Client complaints of pain B) Client history C) Client's chief complaint D) Client interventions

Client complaints of pain

What is the nurse's best defense if a client alleges nursing negligence? A) Testimony of other nurses B) Testimony of expert witnesses C) Client's record D) Client's family

Client's record

A nurse is manually documenting information related to a client condition. When documenting this information, the nurse makes a error on the manual record sheet. Which is the best technique for recording the error in documentation? A.) erase the incorrect statement and write the correct one B.) cross out the wrong statement in a way that it is not readable C.) use correction fluid to obliterate what has been written D.) cross out the incorrect statement with a single line

Cross out the incorrect statement with a single line.

A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to assure maximum efficiency of change of shift reports? A.) pay curtesy calls to staff member before attending the meeting B.) wait for the physicians to arrive before exchanging notes C.) avoid asking questions related t the medical record D.) come prepared with material required to take notes

D.) Come prepared with material required to take notes.

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

D.) timeliness

A nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to nursing? A) Data, information, knowledge B) Process, documentation, analysis C) Research, controls, variables D) Hypothesis, nursing, practice

Data, information, knowledge

What part of the client's record is commonly used to document specific client variables, such as vital signs? A) Progress notes B) Nursing notes C) Critical paths D) Graphic record

Graphic record

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the health care provider? A) ISBAR B) EMAR C) SOAP D) CBE

ISBAR

A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next? A) Date it and put it in the client's record. B) Sign it and put it in the Kardex. C) Individualize it to the specific client. D) Use it as printed, based on common needs.

Individualize it to the specific client.

A nurse caring for a client who is being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation? A) Information is documented in separate forms by each health care personnel. B) It is a unified, cooperative approach for resolving the client's problems. C) It is organized at one location according to the client's health problems. D) It is compiled to facilitate communication among health care professionals.

Information is documented in separate forms by each health care personnel.

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? A) Client assessment B) Intervention carried out C) Written plan of care D) Multidisciplinary interventions

Intervention carried out

A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called? A) Nursing care conferences B) Staff visits C) Interdisciplinary referrals D) Nursing care rounds

Nursing care rounds

A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as the first step? A) Plan of care B) Data, action, and response C) Problem selected D) Nursing activities during a shift

Problem selected

Which one of the following methods of documentation is organized around client diagnoses rather than around patient information? A) Problem-oriented medical record (POMR) B) Source-oriented record C) PIE charting system D) focus charting

Problem-oriented medical record (POMR)

In what type of documentation method would a nurse document narrative notes in a nursing section? A) Problem-oriented medical record B) Source-oriented record C) PIE charting system D) Focus charting

Source-oriented record

SOAP format

Stands for Subjective data, Objective data, Assessment, Plan. Is used to organize entries in the progress notes of the POMR

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which of the following would be most appropriate for the nurse to do? A) Completely erase or delete the erroneous entry if possible. B) Use a highlighter to mark the incorrect entry and place initials next to it. C) Strike out the entry with a single line, place initials next to it, and write the correct entry. D) Black out the erroneous entry with a dark pen or marker.

Strike out the entry with a single line, place initials next to it, and write the correct entry.

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which of the following? A) The physician's assessment and treatment B) Results of laboratory and diagnostic studies C) Nursing documentation and plan of care D) Information from other members of the health care team

The physician's assessment and treatment

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? A) Vulnerability to legal liability since nurse's safe, routine care is not recorded B) Increased workload for nurses in order to complete necessary documentation C) Failure to identify and record client problems and associated interventions D) Significant differences in the charting between nurses due to lack of standardization

Vulnerability to legal liability since nurse's safe, routine care is not recorded

The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which of the following clinical situations? A) When communicating a client's change in condition to the client's physician B) When providing a change-of-shift report to a colleague C) When documenting the care that was provided to a client whose condition recently deteriorated D) When reporting to a client's family member or significant other

When communicating a client's change in condition to the client's physician

patient record

a compilation of a patient's health information

minimum data set

a core set of screening, clinical, and functional status elements that form the foundation of the comprehensive assessment of all residents in long-term care facilities certified to participate in Medicare or Medicaid

graphic record

a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temp, weight, fluid intake and output, bowel movements, and other patients characteristics

outcome and assessment information set (OASIS)

a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement

source-oriented record

a paper format in which each health care group keeps data on its own separate form. It is sectioned off for nurses, healthcare providers, laboratory, x-ray personnel, and so on.

charting by exception (CBE)

a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes.

bedside report

a streamlined shift report system at the bedside

incident/variance report

a 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. not intended for disciplinary actions against staff members

health information exchange (HIE)

allows doctors, nurses, pharmacists, other health cre providers, and patients to appropriately access and securely share a patient's vital medical information electronically, improving the speed, cost, and quality of patient care

critical/collaborative pathway

also called care mas, used in the case management model. Specifies the care plan linked to expected outcomes along a timeline.

focus charting

brings the focus of care back to the patient and the patient's concerns, incorporates many aspects of a patient and patient care

ISBAR communication

communication technique used as a framework for communication between member of the health care team abut a patient's condition

electronic health record (EHR)

computer based records where data can be distributed among many caregivers in a standardized format, allowing them to compare and uniformly evaluate patient progress easily.

personal health record (PHR)

contain the person's medical history, including diagnosis, symptoms, and medications. Doctor's note, test results, CT images, and insurance info can be scanned on.

change-of-shift report/handoff

given by a primary nurse to the nurse replacing him/her, or by the charge nurse to the nurse who assumes responsibility for continuing care of the patient

flow sheet

documentation tools used to efficiently record routine aspects of nursing care, promotes patient goal, achievement, safety, and well-being

progress notes

notes written to inform the caregivers of the progress a patient is making toward achieving expected outcomes

problem-oriented medical record (POMR)

organized around a patient's problems rather than around sources of information. Advantages include entire health care team works together in identifying a master list of patient's problems and contributes collaboratively to the care plan.

narrative notes

progress notes written by nurses in a source-oriented record that address routine care, normal findings, and patient problems identified in the care plan.

consultation

the process of inviting another professional to evaluate the patient and make recommendations to you about a patients treatment

referral

the process of sending or guiding the patient to another source for assistance

occurrence/variance charting

the usual format is the unexpected event, and discharge planning, when appropriate. The variances most likely to be documented are those that affect quality, cost, or length of stay

documentation

the written or electronic legal record of all pertinent interactions with the patient: assessing, diagnosing, planning, implementing, and evaluating