Chapter 4: Documentation and Interprofessional Communication
When performing an assessment, which of the following would be most helpful in validating a client's chief complaint?
Objective data
What is the nurse's best defense if a client alleges nursing negligence?
Patient's record
While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding?
"Area of non-blanching erythema noted over client's coccyx, 2 cm x 2 cm"
During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?
"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room"
A nurse is in the elevator at the hospital. The nurse overhears another nurse laughing and making jokes about a client. Why is this situation a breach of confidentiality?
All client information is private and confidential
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use?
An assessment flow chart
The nurse assesses all assigned clients and sits in the nursing station to document assessment data for all clients. This is an example of:
Batch charting
A nurse is working on a unit for clients with neurological conditions. Which assessment form would the nurse most likely use to document assessment data?
Focused assessment form
The nurse is providing an in-service to a group of students about the benefits that electronic health records (EHRs) bring to health care. The nurse realizes the communication with the students has been successful when they restate which advantage(s) when using EHRs? Select all that apply
Improvement in risk management Prevention of provider liability Improvement in public health and client outcomes Reduction in errors
A hospital is revising the policies and procedures surrounding documentation in an effort to align practices with the Health Information Technology for Economic and Clinical Health (HITECH) Act. How can the requirements of this legislation best be met?
Increase the use of electronic health records (EHRs) in the hospital
Examples of objective data include all the following except
Itchy skin
A computerized risk assessment report correlates data and provides scores on various aspects of clients in the health care facility. Why would this be beneficial for client care?
Notifies health care providers when clients show clinical signs of deterioration
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 nursing implementing?
SOAP charting
After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information as which of the following?
Subjective data and objective data
A nurse is instructing the nursing student on strategies for reducing high-risk errors in documentation. Which examples should the nurse include when teaching the nursing student? Select all that apply.
The nurse takes and records the client's heart rate before administering digoxin The nurse notes the return of bowel sounds following the client's surgery. The nurse administers pain medication when the client reports a pain rating of 7.
After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?
To communicate effectively with other health care team members
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 nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?
Ask the other nurse to read back what the first nurse reported
A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document?
Decreased range of motion in right shoulder
A client is being discharged from the hospital after a below-the-knee amputation. The nurse has completed the discharge and gives a copy of the discharge summary with client teaching and medications to the client. The nurse understands the importance of doing a good assessment prior to discharge for which of the following purposes:
Identify necessary resources and strategies for successful home management
What are the purposes of them medical record? Select all that apply
Legal document Communication between health care members Quality assurance Research
A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?Sub
The laboratory assistant can only retrieve medical records but cannot view the details