Chp 19: Documenting and Reporting (PrepU)

Which is the proper way to document midnight in a client's record? A. 0000 B. 1200 C. 1201 D. 2401

A. 0000

What dual purpose does an audit serve? A. quality assurance and reimbursement B. education and confidentiality C. knowledge and quality D. communication and evaluation

A. quality assurance and reimbursement

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? A. A never event B. An audit C. A variance D. A sentinel event

C. A variance

Which pieces of information should the nurse treat as confidential and not disclose? Select all that apply. A. A client's address B. A deceased client's history for organ donation C. A client's Social Security number D. Information about a client's past health conditions E. A client's diagnosis linked to a disease outbreak

A. A client's address C. A client's Social Security number D. Information about a client's past health conditions

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. A, Obscuring identifiable names of clients and private information about clients on clipboards B. Keeping record of people who have access to clients' records C. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public D. Making the names of clients on charts visible to the public E. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards

A, Obscuring identifiable names of clients and private information about clients on clipboards B. Keeping record of people who have access to clients' records C. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public

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 nurse implementing? A. SOAP charting B. narrative charting C. PIE charting D. FOCUS charting

A. SOAP charting

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? A. progress notes B. plan of care C. data base D. problem list

A. progress notes

Which statement about client records and documentation is correct? A. Physicians will not review nurses' documentation in the client's record. B. Nurses should not document progress notes in a client's record. C. Clients should keep the original record at home in a fireproof safe. D. Communication is the primary purpose of client records.

D. Communication is the primary purpose of client records.

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

D. Reporting

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

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

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? A. MAR B. PIE C. SBAR D. SOAP

C. SBAR

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: A. factual statement. B. relevant data. C. important information. D. interpretation of data.

D. interpretation of data.

Which abbreviation is correct for use in documentation? A. PO B. BT C. Per os D. Sub q

A. PO

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse? A. "Legal policy requires nursing practice to be permanently integrated into the client record." B. "The facility requires us to document client care this way because of the computer application used." C."The electronic health record we use does not allow us to use different formats." D. "It would be easier to do it that way. You could develop a tool to use."

A. "Legal policy requires nursing practice to be permanently integrated into the client record."

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

C. Intake and output graphic sheet

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? A. pain rating of 4 on a scale of 0-10 B. describes wound as itchy C. urine output 100 ml D. concerned with feeling tired

C. urine output 100 ml

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records? A. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. B. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. C. Problem-oriented recording has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care. D. Problem-oriented recording gives clients the right to withhold the release of their information to anyone.

A. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: A.have the right to copy their health records. B. are required to obtain health record information through their insurance company. C. can be punished for violating guidelines. D. need to obtain legal representation to update their health records.

A.have the right to copy their health records.

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

B. The physician's assessment and treatment

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? A. "Only authorized persons are allowed to access client records." B. "I am sorry I can't access that information." C. "Let me get that for you." D. "The provider will need to give permission for you to review."

A. "Only authorized persons are allowed to access client records."

Which note includes all elements of a SOAP note? A. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness. B. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. C. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess. D. Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min.

A. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation?

Attach a copy of the incident report to the chart.

The nurse is caring for a postoperative client who is experiencing hypotension. When contacting the client's health care provider, the nurse will include which statement in the SBAR report? Select all that apply. A. "The client is very distressed. I am very concerned about how the client is coping right now." B. "The client was just admitted to this unit from postanesthesia recovery after having abdominal surgery." C. "The client demonstrates additional signs of hypovolemia including slow capillary refill." D. " I have diagnosed the client with an internal bleed and need orders to treat accordingly." E. "The client has had a sudden drop in blood pressure from 125/90 down to 90/60 mm Hg."

B. "The client was just admitted to this unit from postanesthesia recovery after having abdominal surgery." C. "The client demonstrates additional signs of hypovolemia including slow capillary refill." E. "The client has had a sudden drop in blood pressure from 125/90 down to 90/60 mm Hg."

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? A. Asking the emergency department nurse for information on the family member B. Calling the client information desk to find out the room number of the family member C. Finding the emergency medical technicians who transported the family members and inquiring about the injuries D. Accessing the electronic health record of the family member to find out extent of injury

B. Calling the client information desk to find out the room number of the family member

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information? A. Client states expecting some pain, but it is more severe than anticipated. B. Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." C. Client is requesting pain medications, is grimacing, and is diaphoretic. D. Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants.

B. Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

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? A. "Let me open up the computer access so that you can see what information is of interest to you." B. "You may not understand all of the information and it will confuse you so I will help you decipher it all." C. "I will have to review the policy that determines what procedure is in place for client access." D. "The hospital owns your records and does not have to allow you access while you are a client here."

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

The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development? A."The care plan shows the medical diagnosis for the client." B. "The care plan provides additional documentation about the work of the nurse." C. "The care plan is required for every client by The Joint Commission." D. "The care plan is the only way for nurses to document what they do."

C. "The care plan is required for every client by The Joint Commission."

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records? A. "The clients' medical records provide data for legal evidence." B. "The clients' health records should be used to promote reimbursement from insurance companies" C. "The clients' medical records are an obstruction to research and education." D. "I can share the clients' medical records with the health care team."

C. "The clients' medical records are an obstruction to research and education."

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

C. A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? A. It documents assessments on separate forms. B. It records progress under problems, intervention, and evaluation. C. It provides quick access to abnormal findings. D. It provides and refers to a client's problem by a number.

C. It provides quick access to abnormal findings.

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

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

When maintaining health care 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 legally defensible charting? A. Leave spaces between entries and signature. B. Use abbreviations wherever possible. C. Record all facts and subjective interpretations. D. Ensure that the client's name appears on all pages.

D. Ensure that the client's name appears on all pages.

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

D. identifying risks and ensuring future safety for clients

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? A. organization B. reimbursement C. objectivity D. subjectivity

D. subjectivity

The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply. A. Faxing the results of blood chemistry levels to the provider's office B. Placing a note on the computer terminal with the client's name and information C. Informing the provider of the client's present heart rate of 116 beats/min D. Showing the provider the trends from baseline to present in blood pressure E. Writing the hemoccult result on a piece of paper and leaving it at the desk

A. Faxing the results of blood chemistry levels to the provider's office C. Informing the provider of the client's present heart rate of 116 beats/min D. Showing the provider the trends from baseline to present in blood pressure

The nurse is calling a health care provider to give an update on a client's condition. The nurse receives a telephone order and, when requests that the order be read back to the provider for confirmation, the provider states, "I don't have time for this." What is the most appropriate action by the nurse? A. Inform the provider, to ensure safety for the client, it must be read back B. Don't follow through with the order, and delete it from the record C. Ask the secretary to call the provider back and take the order D. Proceed with the order since the nurse heard it the first time

A. Inform the provider, to ensure safety for the client, it must be read back

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation? A. Source-oriented B. Charting by exception C. Problem-oriented D. PIE charting

A. Source-oriented

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

A. those directly involved in the client's care

A nurse helps a client who has cystic fibrosis prepare a stand-alone personal health record. Which statement by the nurse best explains this type of information? A. "You can link your record to a specific health care organization's electronic health record system." B. "You can fill in information from your own records and store it on your computer or the Internet." C. "Your health care provider is obligated to read your personal health record and share it with your insurance provider." D. "Your entire health care team may access and securely share your vital medical information electronically."

B. "You can fill in information from your own records and store it on your computer or the Internet."

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? A. Care plan and client's record B. Client's record and occurrence report C. Occurrence report and critical pathway D. Critical pathway and care plan

B. Client's record and occurrence report

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error? A. Contact information technology (IT) staff to make the correction. B. Create an addendum with a correction. C. Contact the health care provider. D. Immediately delete the incorrect documentation.

B. Create an addendum with a correction.

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator? A. Talking directly to the translator facilitates the transfer of information. B. Translators may need additional explanations of medical terms. C. Talking loudly helps the translator and the client understand the information better. D. It is always okay to not use a translator if a family member can do it.

B. Translators may need additional explanations of medical terms.

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply. A. what the client watched on television during the shift B. any abnormal occurrences with the client during the shift C. identifying demographics, including diagnosis D. current orders E. what time the nurse will return for the next shift

B. any abnormal occurrences with the client during the shift C. identifying demographics, including diagnosis D. current orders

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation? A. SOAP B. charting by exception C. focus D. narrative

B. charting by exception

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

B. limiting abbreviations to those approved for use by the institution.

Which organization audits charts regularly? A. Sigma Theta Tau International B. National League for Nursing C. The Joint Commission D. American Nurses Association

C. The Joint Commission

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? A. Place the narrative note chronologically after the respiratory therapist's note. B. Review the laboratory results under the physician section. C. Write a narrative note in the designated nursing section. D. Use a critical pathway to document the physical assessment.

C. Write a narrative note in the designated nursing section.

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? A. "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin." B. "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." C. "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." D. "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."

D. "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."

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? A. "It makes our client feel like we care, especially if we start the day off with a clean room." B. "It will give me a better sense of what my workload will be today." C. "It will let me see everything that has been done and things that need to be done." D. "It will allow for us to see the client and possibly increase client participation in care."

D. "It will allow for us to see the client and possibly increase client participation in care."

A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift? A. "The client was very restless last night so you may need to call the health care provider today to get a prescription for the client's anxiety." B. "The unlicensed assistive personnel turned the client every 2 hours last night, but the client should continue to be repositioned during the day." C. "No medical issues overnight that require immediate attention." D. "The client had a good deal of anxiety last night and requested to be turned and repositioned frequently."

D. "The client had a good deal of anxiety last night and requested to be turned and repositioned frequently."

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR? A. "The client was admitted today with a urinary tract infection." B. "I am concerned that the client might be exhibiting sepsis." C. "The client's temperature has been 102°F (38.9°C) for the last 6 hours." D. "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

D. "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

Which principle should guide the nurse's documentation of entries on the client's health care record? A. Nurses should not refer to the names of physicians. B. Documentation does not include photographs. C. Correcting fluid is used rather than erasing errors. D. Precise measurements should be used rather than approximations.

D. Precise measurements should be used rather than approximations.

A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse best reflects the effectiveness of the pain medication? A. Vital signs within normal limits, sleeping. B. States pain is not relieved, talking with family on phone. C. Rates pain higher on pain scale, notified physician. D. Rates pain 8/10, states nauseated for last 30 minutes.

D. Rates pain 8/10, states nauseated for last 30 minutes.

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? A. Heart rate and rhythm B. The abdominal area C. Lung sounds D. The lower extremities

D. The lower extremities

Which documentation by the nurse best supports the PIE charting system? A. Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea B. States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given C. Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg D. Vomiting 250 mL undigested food, antiemetic given, no further vomiting

D. Vomiting 250 mL undigested food, antiemetic given, no further vomiting