Chapter 4- Documentation and Interprofessional Communication

a nurse is documenting a client's headache. which of the following would be the best entry to include for this finding?

client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.

during the admission assessment, the nurse notes the client has cuts to her face and bruises on her chest and back. which of the following demonstrates the most appropriate documentation of these findings?

dark purple-blue area on the right side of chest and on right lower back. open areas on the left side of the lower lip and above right eye

a nurse is explaining to other nurses on the unit about diagnosis-related groups (DRGs). on what documentation do insurance companies base their payment approval/disapproval?

diagnosis codes

the nurse prepares information to provide to the nurse scheduled to work the next shift. which type of communication is the nurse preparing?

handoff report

how does the client's medical record affect financial reimbursement? (select all that apply.)

insurance companies audit client records to ensure that billing is accurate

an audit of a hospital unit's incident reports reveals that several errors have resulted from incomplete or inaccurate information during change-of-shift handoff. in order to prevent such errors, what practice should be encouraged on the unit?

involve as few people as possible in the verbal report

a new nurse is unfamiliar with the electronic charting system in use at the institution. what positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?

it allows several health team members to view the client record simultaneously

what statement about batch charting is most accurate?

it contributes to many potential errors

which of the following examples of documentation best exemplifies sound clinical documentation practices?

"non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter"

which of the following clinical situations 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

a nurse has just finished assessing a client. which of the following are objective data that the nurse would likely have gathered? select all that apply.

a description of a large bruise on the client's thigh the client's weight the presence of a lump in the client's breast discovered on palpation

a nurse assesses a series of clients throughout the day and obtains the findings listed below. which finding would require validation?

a weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight

a nursing instructor is teaching students about the principles governing documentation. the teacher emphasizes that quality documentation remains confidential and is also (check all that apply):

accurate organized complete timely concise

the nurse responds to a call light for a client rating their pain "ten out of ten." the nurse's initial inspection reveals the client is watching videos and appears to be at ease physically and emotionally. how should the nurse validate the client's subjective complaint of pain?

perform further assessments addressing various aspects of the client's pain

a nurse is currently in the assessment phase of the nursing process with a client. which pieces of information should the nurse document during this phase? select all that apply.

physical assessment data nursing history information provided by the client

a client's pain has become increasingly severe, but the client has received the maximum doses of analgesics. the nurse is receiving a new analgesic order from the health care provider. how would the nurse best validate the new order?

read the order back to the health care provider for confirmation

a nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. when consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. his blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. the client's weight has remained the same. the nurse realizes that the data need to be validated. which method of validation would be most appropriate in this case?

repeating the measurement with a different sphygmomanometer and stethoscope

a client is being discharged home. the discharge note that the nurse writes for this client provides information for what purpose?

resources and strategies for managing the client at home

which example may illustrate a breach of confidentiality and security of client information?

the nurse provides information over the phone to the client's family member who lives in a neighboring state