DOCUMENTING

When documenting client care, which principles should the nurse strive for? Select all that apply. Chapter 19: Documenting and Reporting - Page 453 Subjectivity Timeliness Accuracy Objectivity Confidentiality

Confidentiality Accuracy Objectivity Timeliness The principles of proper documentation include confidentiality, accuracy, completeness, conciseness, objectivity, organization, timeliness, and legibility. The nurse should not strive for subjectivity when documenting.

Interval or progress notes

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

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? Chapter 19: Documenting and Reporting - Page 474 Verification Documentation Reporting Dialogue

Reporting Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. .Some facilities may use encrypted (protected) software programs such as Share Point or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.

Which pieces of information should the nurse treat as confidential and not disclose? Select all that apply. Chapter 19: Documenting and Reporting - Page 458

A client's Social Security number Information about a client's past health conditions A client's address Client information that is considered confidential includes client names and all identifiers, such as address, telephone and fax number, Social Security number, and any other personal information. It also includes the reason the client is sick or in the hospital, office, or clinic, the assessments and treatments the client receives, and information about past health conditions. Exceptions to confidentiality include disclosure of client information for the purpose of tracking and notification of disease outbreaks and information about a deceased person's organ donation.

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 Telemedicine report Transfer report Nurse's shift 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 nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process? Chapter 19: Documenting and Reporting - Page 479 The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. The nurse sends or directs someone to take action in a specific nursing care problem. The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

The nurse meets with nurses or other health care professionals to discuss some aspect of client care. A nursing care conference is a meeting of nurses to discuss some aspect of a client's care.

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? Chapter 19: Documenting and Reporting - Page 232

SBAR The nurse should use SBAR (situation, background, assessment, recommendation) when communicating with the health care provider. SOAP and PIE are nursing notes in the medical record, and MAR is medication administration record.

GO OVER: Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? Chapter 19: Documenting and Reporting - Page 457 Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information Submitting a written notice to all clients identifying the uses and disclosures of their health information Disclosing client health information for research purposes after obtaining permission from the client's physician Releasing the client's entire health record when only portions of the information are needed

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 required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the physician's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations.

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? Chapter 19: Documenting and Reporting - Page 479 Translators may need additional explanations of medical terms. It is always okay to not use a translator if a family member can do it. Talking loudly helps the translator and the client understand the information better. Talking directly to the translator facilitates the transfer of information.

Translators may need additional explanations of medical terms. When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times.

GO OVER: 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? Chapter 19: Documenting and Reporting - Page 468 plan of care problem list progress notes data base

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.