documentation ch 16 coursepoint

A client is scheduled for a CABG procedure. What information should the nurse provide to the client?

"A coronary artery bypass graft will benefit your heart." Coronary artery bypass graft is abbreviated CABG. It does not identify nutritional needs, decrease liver inflammation, or increase intestinal motility.

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate?

Ask the client if information can be given to the parent. No information should be provided by the nurse without permission from the client. Taking the parents to the client's room to get information from the client may violate the client's privacy

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?

Calling the client information desk to find out the room number of the family member Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

Which is not a purpose of the patient care record?

Contract Patient care records are legal documents, communication tools, and assessment tools. They are used for care planning purposes, quality assurance purposes, for reimbursement, research, and education.

According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation Documentation is the primary source of evidence used to measure performance outcomes, according to the CNA.

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

Reporting Reporting takes place when two or more people communicate information about client care, either face to face, or by recording, computer charting, or telephone. Dialogue is two-way communication, which is not always the case for reporting.

The nursing is caring for a client who requests to see a copy of his health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records. The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the records.

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 Use abbreviations, but only those that are commonly accepted and approved by the facility.

To improve communication within the health care system, tools were created to standardize the process and assist with clarity and conciseness. SBAR is one such tool. In this tool, what does R stand for?

Recommendations SBAR stands for Situation, Background, Assessment, and Recommendations.

Which documentation by the nurse best supports the PIE charting system?

Vomiting 250 mL undigested food, antiemetic given, no further vomiting PIE charting includes the Problem, Intervention, and Evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (Problem), antiemetic given (Intervention), no further vomiting (Evaluation).

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?

subjectivity. Quoting what the client is saying helps in the documentation of subjective data. Objective data is assessment data that may be directly observed by the nurse such as blood pressure. Organization is the structure of the documentation and does not relate to subjective data. Reimbursement is a distractor that doesn't relate to assessment data.

Which statement is not true regarding a medication administration record (MAR)?

If the client refuses the dose you don't have to document this on the MAR. If a client refuses a dose, it is important to circle that dose and write a note as to why you did not administer it.

A nurse is taking care of a client post knee surgery. The nurse follows a clinical pathway that guides the care of this client after this specific procedure. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What does the nurse identify this even as?

variance. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed, documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb, or a serious injury to a client.

During hospitalization, the client has developed shortness of breath, with edema. What action should the nurse take?

Revise the plan of care. A plan of care should be generated at admission and revised to reflect changes in the client's condition.

The parents of a hospitalized child ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?

"I will arrange access for you to review the record after you put your request in writing." Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. It is the parents' right to view the client's record. Therefore, the statements about the physician not giving the parents access to review the records and asking if the parents have specific questions are incorrect. The client is a minor, so the legal guardian has the right to view the records

The nurse in making an entry on the client's charted "Medicated with meperidine 50 mg at midnight." How would the nurse document the entry using military time?

0000 0000 is the military time for midnight and is correct. The other military times are incorrect, since 2401 is 1 minute passed midnight, 1200 is noon, and 1201 is 1 minute passed noon.

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records?

"The clients' medical records are obstruction to research and education." The clients' medical records are good sources of data for research and education, and, therefore, it is incorrect to say that they are an obstruction. The other statements do not need correction.

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:

Although not written, the nurse must know or question the rationale before performing an action. Although the scientific rationale is not documented in the clinical plan, it is no less important than in the instructional plan. Nurses and other members of the healthcare team must know the rationale behind the intervention or must question and review the rationale before performing the action.

The nurse recognizes that documentation of one client's assessment data is on another client's health care record. Which action should the nurse take?

Draw a single line through the error, and initial it When an error occurs, the nurse should draw a single line through the error and place his or her initials above it.

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 legal defensible charting?

Ensure that the client's name appears on all pages. The nurse should ensure that the client's name appears on all pages to ensure legally defensible charting. The nurse should not leave spaces between entries and signature so that the document is legally acceptable. The nurse should use only abbreviations approved by the facility, and should not use abbreviations wherever possible. The nurse should record all the facts but not any subjective interpretations, to ensure that the document is legal evidence.

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." HIPAA has created several changes that protect client confidentiality and affect the workplace. One such change is that the names of clients on charts can no longer be visible to the public, and clipboards must obscure identifiable names of clients and private information about them. Therefore, writing down clinical information, taking the data off the unit, and including client identifiers are inappropriate statements.

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?

"It will allow for us to see the client and possibly increase client participation in care." Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records." The client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. The other answers are therefore inappropriate responses.

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?

Client's record and occurrence report An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.

Which principle should guide the nurse's documentation of entries on the client's health care record?

Precise measurements should be used rather than approximations. Precise measurements and times must be used whenever possible. It is appropriate to use the names of physicians, and photographs can constitute documentation. Handwritten entries should be struck through with a single line, not covered with correcting fluid or erased.

What dual purpose does an audit serve?

Quality assurance and reimbursement Audits of client records serve a dual purpose: quality assurance and reimbursement.

The nurse hears an unlicensed assitive personel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

Remind the UAP about the client's right to privacy. The nurse should first remind the UAP about the client's right to privacy. All other actions are appropriate, but do not immediately protect the client's privacy.

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

urine output 100 ml Objective data is collected by the nurse, such as the measurable urine output. Subjective data, such as feeling pain, itchiness, or fatigue, is reported by the client.

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

A flow sheet A flow sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special needs.

What ensures continuity of care?

Communication Communication ensures continuity of care and provides essential data for revision or continuation of care.

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate?

Explain the reason why information cannot be disclosed. The nurse needs to explain the reason why information cannot be released to the parents. Providing insurance coverage does not negate the privacy laws. Referring the parent to the physician is inappropriate since the physician cannot release the information either. Mediating a meeting between the parent and client would only be appropriate if the client requested the meeting.

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?

SOAP charting The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

The nurse is completing documentation for a newly admitted client. Which entries should the nurse include in charting? Select all that apply.

The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. The client was overheard telling a family member about more bleeding than reported The dressing has a 5 cm area of bloody drainage The client's pupils are equal, reactive, to light and accommodation Entries must be accurate. Nurses must chart only observations that they have seen, heard, smelled, or felt. An observation made by another health professional must be clearly identified as such.

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate?

Write a narrative note in the designated nursing section. Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the physician section. Critical pathways are not used to document physical assessments.

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mm Hg when all other vital signs are normal. This reflects what type of documentation?

charting by exception Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. In the scenario, the BP is abnormal and is documented by exception. The other types of documentation are not being represented in this scenario.

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. In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?

Subjective data should be included when documenting. Subjective data should be included when using the SOAP format for documentation. Objective data is what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care providers' judgment of the situation, and abnormal lab values would be included in objective data.

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 refuses. The nurse's refusal is based on the understanding that which people would be entitled to access of the client's records?

those directly involved in the client's care Only those directly involved in client care are entitled to access the client's information. Family members and close friends do not have access to the client's records, as per the privacy policy of the client. Health care professionals of the health care facility cannot access client information unless involved in client care.

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

"According to HIPAA legislation, you have a right to request changes to inaccurate information." The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records, and they can also obtain a copy of it. Therefore, clients reserve the right to request changes in accurate information. The other responses are inaccurate.

A nurse is transfusing multiple units of packed red blood cells (PRBCs). After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication?

"I think the client would benefit from intravenous furosemide." Situation, Background, Assessment, and Recommendations provides a consistent method for hand-off communication that is clear, structured, and easy to use. This technique was originally developed by the U.S. Navy to accurately transmit critical information and initially adapted by Kaiser Permanente of Colorado to facilitate nurse and physician communication. The S (Situation) and B (Background) provide objective data, whereas the A (Assessment) and R (Recommendations) allow for presentation of subjective information. Calling to report dyspnea and crackles occurs as the nurse describes the situation. Providing the medical history occurs as the nurse offers important background information. Stating the client has fluid volume overload is the assessment of the nurse.

The nurse is using the ISBARR format to report a surgical client's deteriorating condition to a health care provider. Which actions would the nurse perform when using this guide? Select all that apply.

After introductions, the nurse states the client name, room number, and problem. The nurse states that the client's condition "could be life-threatening." The nurse reads back the physician's new orders at the conclusion of the call. The ISBARR format is an effective tool for communication in the health care setting. This template outlines the conversation to occur between the nurse and the health care provider in the question above. The nurse would perform the following actions when using this guide: • after introductions, the nurse would state the client name and other important demographic information regarding the client • the nurse could potentially state that the client's condition "could be life-threatening," • the nurse reads back the health care provider's new orders at the conclusion of the call. The nurse would not ask the health care provider to describe the admitting diagnosis of the client. The nurse would not ask the health care provider to estimate the discharge date for the client. The nurse would not ask the health care provider to comment on the present situation before giving recommendations.

An informatics nurse is assisting with the development of a new clinical information system that will be implemented in the facility. As part of the process, the team is evaluating the purpose of the system and the technological options available. The team is in which phase of the system development lifecycle?

Analyze and plan During the analyze and plan phase, questions related to the purpose, the problem being solved, and the technological options available are addressed. Design addresses the display characteristics, whether the design supports or improves workflow, and recommendations for design based on evidence. The test phase involves how the components of the system work. The train phase involves teaching of the end users.

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?

Incident report An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.

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?

Inform the health care provider that a written order is needed. Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.

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?

It provides quick access to abnormal findings. Charting by exception (CBE) provides quick access to abnormal findings as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

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?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among healthcare providers is an advantage of problem-oriented recording and is therefore correct. Giving the clients the right to withhold the release of their information to anyone is beneficial disclosure, and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving the clients' problem among caregivers and having numerous locations for information where each member of the multidisciplinary team makes entries about their own specific activities in relation to the client's care are examples of source-oriented recording.

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 In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.

A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply.

S: The nurse handling the transfer describes the client situation to the new nurse. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse gives recommendations for future care to the new nurse in charge. Examples of using the SBAR technique are numerous. The nurse handling the transfer describes the client situation to the new nurse. The nurse gives the background of the client by explaining the client history. The nurse presents an assessment of the client to the new nurse. The nurse gives recommendations for future care to the new nurse in charge. The nurse does not explain the rules of the new facility to the client as part of the SBAR technique. The nurse would discuss the client's symptoms with the new nurse in charge as part of the "B" background, not the "S" situation.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions. Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by the Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health history and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation.

A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy?

Use minimum disclosure policy to release the information. The nurse should use minimum disclosure policy to release the information, as per HIPAA regulations. It is inappropriate to not release any information to the insurance company, to refer the insurance agent directly to the client, and to release the full medical record to expedite payment.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?

a client who is homebound and needs skilled nursing care Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease, and their families. Providing this information is an example of:

a referral. Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs oedmatous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now oedema +"?

focus charting Focus charting is correct, as it gives priority attention to the client's current or changed behavior. Pie charting occurs when the nurse records the client's progress under the headings of problem, intervention, and evaluation. Narrative charting content resembles a log or journal entry. Charting by exception is charting only abnormal assessment findings that deviate from a standard norm. Therefore, this nurse is not demonstrating pie, narrative, or exception charting.

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?

identifying risks and ensuring future safety for clients Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data. A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretation. Relevant and important information and data can be used to support the interpretation statement such as documenting that the client is sitting in their room in the chair without lights on or no visitors visited the client today.

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document. The client record serves as a legal document of the client's health status and care received.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

omitting client's response to nursing interventions Omitting the client's response to nursing interventions is correct because it does not fit the criteria for legally defensible charting. Recording appropriate nursing interventions, identifying nursing diagnoses or client needs, and documenting clients' health history and discharge planning are all criteria for legally defensible charting and would demonstrate evidence of quality care.

A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis?

public health department Notifying the public health department of communicable disease is considered an exemption for beneficial disclosure. Health Canada is not involved in individual incidences of illness. The client's employer is not privy to the information for confidentiality reasons.

To which Health Insurance Portability and Accountability Act regulation should the nurse adhere when safeguarding clients' written, spoken, and electronic information?

submitting a written notice to all clients identifying the uses and disclosures of their health information Submitting a written notice to all clients identifying the uses and disclosures of their health information is correct. The Health Insurance Portability and Accountability Act (HIPAA) protects the privacy of health records and the security of that data. Failing to recognize the client's right to withhold health information for research, releasing the client's entire health record when only portions of the information are needed, and failing to obtain the client's signature indicating that the client was informed of the disclosure of information are incorrect, as these are HIPAA violations.