Foundations Exam 1: Chapter 16 - Documentation

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, medical records cannot be changed." "HIPAA legislation allows for you to change any information." "According to HIPAA legislation, you have a right to request changes to inaccurate information." "HIPAA legislation only allows access to review the medical record."

"According to HIPAA legislation, you have a right to request changes to inaccurate information."

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." "Be sure to write down specific information for your clinical paperwork." "Be sure to put the client's name and room number on all paperwork." "You can get an electronic print out of client lab data to take with you."

"Clipboards with client data should not leave the unit."

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

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

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 in to 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? Fill out an incident report. Attach a copy of the incident report to the chart. Stop the infusion and document the time. Report error to primary provider.

Attach a copy of the incident report to the chart.

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. Access the health care record at the bedside and show the client how to navigate the electronic health record. Discuss how the hospital can be fined for allowing clients to view their health care records. Explain that only a paper copy of the health care record can be viewed by the client.

Review the hospital's process for allowing clients to view their health care records.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a client whose status is stabilized a client who is homebound and needs skilled nursing care a client who is not making progress in expected outcomes of care a client whose rehabilitation potential is not good

a client who is homebound and needs skilled nursing 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. a consultation. reporting. conferring.

a referral.

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

have the right to copy their health records.

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 gauging the nurse's professional performance over time protecting the nurse and the hospital from litigation following up the incident with other members of the care team

identifying risks and ensuring future safety for clients

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? recording appropriate nursing interventions identifying nursing diagnoses or clients' needs omitting client's response to nursing interventions documenting client's health history and discharge planning

omitting client's response to nursing interventions

What situation would permit the nurse to disclose information without the client's approval? the nurse sharing details of the client's wills and loans D. the nurse suspecting that a client is being abused or neglected the nurse informing the relatives of the client's noncompliance with treatment the nurse revealing the address of the client's place of residence

the nurse suspecting that a client is being abused or neglected

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." "It will let me see everything that has been done and things that need to be done." "It makes our client feel like we care, especially if we start the day off with a clean room." "It will give me a better sense of what my workload will be today."

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

The nurse manager overhears a nurse say, "I'm not going to fill out an incident report because it will be used against me." What response by the nurse manager is most appropriate? "The main purpose of an incident report is for quality improvement, not disciplinary action." "It is the number of incident reports you fill out that will determine if action will be taken against you." "If you feel the incident was minor, then you don't need to fill out a report." "The best way to not fill out an incident report is to not make a mistake."

"The main purpose of an incident report is for quality improvement, not disciplinary action."

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? 1 Unit of glucose 1 bottle of glucose One U of glucose 1U of glucose

1 Unit of glucose

The nurse is documenting an assessment that was completed at 9:30 pm. The facility uses military time for documentation. What entry should the nurse make for the time care was given? 930 pm 0930 2130 1930

2130

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: Some facilities do not require them on their plans of care. Rationales are only important while the nurse is in training. The use of rationales is not commonly practiced in the clinical setting. Although not written, the nurse must know or question the rationale before performing an action. The rationale is deleted to provide additional charting space in the computer system.

Although not written, the nurse must know or question the rationale before performing an action.

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 Design Test Train

Analyze and plan

What is the primary purpose of the client record? Advocacy Education Research Communication

Communication

The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? Select all that apply. Computer screens must be oriented towards the public view. The names of the clients on charts should be visible to the public. Documentation must be kept of personnel who have accessed a client's record. Light boxes for examining X-rays with the client's name must be in private areas. Conversations about clients must take place in private places where they cannot be overheard.

Documentation must be kept of personnel who have accessed a client's record. Light boxes for examining X-rays with the client's name must be in private areas. Conversations about clients must take place in private places where they cannot be overheard.

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. The MAR distinguishes between routine and "as needed" medications The MAR identifies routine times for medication administration. When using an electronic MAR, the nurse has to log off so that the next person using the computer does not sign off a medication under her name by mistake.

If the client refuses the dose you don't have to document this on the MAR.

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 Nurse's shift report Transfer report Telemedicine report

Incident report

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

Precise measurements should be used rather than approximations.

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 is difficult to demonstrate a unified approach for resolving the clients' problem among caregivers. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Problem-oriented recording has numerous locations for information where each member of the multidisciplinary team makes entry about their own specific activities in relation to the client's care. Problem-oriented recording gives the clients the right to withhold the release of their information to anyone.

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

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? Data base Problem list Plan of care Progress notes

Progress notes

How can a nurse obtain additional information about a client? Call the client's family. Ask the client's sister about the family history. Review nursing literature. Read the client's history and assessment.

Read the client's history and assessment.

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? Reinforcing data Response Recommendations Report

Recommendations

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

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

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

interpretation of data.

To which Health Insurance Portability and Accountability Act regulation should the nurse adhere when safeguarding clients' written, spoken, and electronic information? 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 submitting a written notice to all clients identifying the uses and disclosures of their health information failing to obtain the client's signature, indicating that the client was informed of the disclosure of information

submitting a written notice to all clients identifying the uses and disclosures of their health information

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 any family member of the client close friends of the client health care professionals of the facility

those directly involved in the client's care