HA Chapter 5

SBAR

a form of reporting and communication Situation Background Assessment Recommendation

Common assessments that are generally found on a flowsheet

vital signs intake and output routine assessments diabetic record

Reporting

Occurs at handoffs, during Pt rounds, during PT and family care conferences, and when calling or text-paging a provider to report a change in status or to provide requested info.

OASIS

Outcome and Assesment Information Set

CPOE

computerized provider order entry

Flowsheet

efficient and standardized form that assembles the collected info in a way that permits easy comparison among assessment data to detect trends or a sudden change in status.

Confidentiality

keeping all patient info private

Point of care documentation

occurs when nurses document assessment info as they gather it, often using a portable computer.

Handoff

transfer of care for a PT from one healthcare provider to another.

Charting by exception

use of predetermined standards and norms to record only significant assessment data.

SOAP

used in documentation of abnormal finding Subjective Objective Assessment Plan

DRGs

Diagnostic-Related Groups

Which of the following are advantages of the electronic medical record? Select ALL THAT APPLY A-nurses can enter data by checking boxes and adding full free text B-it is economical and easy to learn and implement C-It allows primary provider to directly order into the computer D-It cannot be used as a legal document in a case of lawsuit

A- Nurses can enter data by checking boxes or entering free full text.

What do the different formats of progress notes have in common ? A-All use the nursing process in some form to show nursing thinking B-All identity the PT outcomes or goals to evaluate. C-All include heat-to-toe assessment data for completeness D-All have a section for evaluating care so that nurses may revise interventions.

A-All use the nursing process in some form to show nursing thinking

Which of the following are acceptable under the HIPAA Privacy rule ? SELECT ALL THAT APPLY A-Communicating report with the next nurse during a change of shift. B-Communicate with primary care provider about a patients change is assessment C-Consult in the hall with the instructor about the patients abnormal findings D- Describe patient assessment findings to a colleague in the cafeteria.

A-Communicating report with the next nurse during a change of shift. & B-Communicate with primary care provider about a patients change is assessment

A nurse new to the hospitals attending orientation with the nurse educator who is discussing documentation of PT care. The Institution uses PIE charting. How would the nurse educator best describe PIE charting? A-Problem, interventions, evaluation B-Position, interaction, evaluation C-Position, Intervention, Exit note D-Problme, intervention, exit note

A-Problem, interventions, evaluation

Which of the following are high-risk assessment s for liability? Select ALL THAT APPLY A- Failure to document completely B-Inadequate admission assessment C-Charting in advance D-Bunch charting at the end of a shift

ALL A- Failure to document completely B-Inadequate admission assessment C-Charting in advance D-Bunch charting at the end of a shift

Why is accurate and effective documentation most important ? A-It keep PT informed about their care B-Documentation constitutes a a legal record C-It ensures that data can be used for research purposes D-It can be used to educate other nurses

B-Documentation constitutes a a legal record

IN the SBAR reporting format, which of the following would be an example of data found in the assessment? A-Mrs.Kelly's diagnosis id stage 2 breast cancer B-Mr. Imami's lung sounds are decreased C-Ms.Choi needs to have a social work consult D-Mrs. Jones was admitted at 10:30 this morning

B-Mr. Imami's lung sounds are decreased

What are some strategies foe effective handoffs during a change-of-shift report? A-Tape record the report for efficiency B-Vary the format to individualize to the patient C-Allow and opportunity to ask and answer questions D-Put report in writing so that the next shift provider can get right to work.

C-Allow and opportunity to ask and answer questions

A nurse is expliainig to other nurses on the unit about DRGs. What do insurance companies use to base their payment approval/disapproval on? A-Medical Diagnosis B-Labratory Tests C-Diagnosis Codes D- Documentation

C-Diagnosis codes

A new nurse is not familiar with the electronic charting that the institution uses. What positive attribute of electronic charting could the nurses preceptor emphasize to this new nurse? A-It maximizes compliance issues B-It disables the graphing of trends in vital signs or assessment data C-It allows several health team members to view the PT record simultaneously D-It automatically corrects both spelling and grammar

C-It allows several health team members to view the PT record simultaneously

What statement about batch charting is most accurate ? A-It provides clear documentation B-It makes the chart available to multiple users C-It contributes to many potential errors D-It facilitates completion i a timely manner

C-It contributes to many potential errors

Which of the following is the purpose of auditing charting? A-to enhance nurses "learning and understanding of complex clinical situations" B-To identify staff members who document completely and counsel those who do not. C-To determine if staff members are providing and documenting standards of care D-To locate data in the chart the evening before a morning clinical.

C-To determine if staff members are providing and documenting standards of care

Your patient with a humerus fracture is stating pain 15 on a 10-point scale. His hand is pale, cool and swollen. His pain meds are ineffective and he is at risk for compartment syndrome. What action will the nurse take first ? A-Reasses the pain and 30 min and contact t he provider if its not resolved B-Give additional pain meds and reassess 30 min later C-Document the abnormal findings and give an extra dose of pain meds now. D- Contact the primary provider an document the findings now

D- Contact the primary provider an document the findings now

During an accrediting agency visit, it is found that some patient care standards are not being met. Where would problem solving occur in this instance ? A-Patient level B-Shift level C-Department level D-Facility level

D- Facility level

Nursing assessment of trends in an unconscious patients neurological status over time is best recorded on A-an admission assessment B-a POC C-A progress note D-A focused assessment flow sheet

D-A focused assessment flow sheet

Which of the following is the correct technique for correcting written documentation ? A-Use white-out and cover over the error B-Completely black out the error with a black marker. C-write over the error in darker ink D-Draw a single line through the error and initial

D-Draw a single line through the error and initial

The nurse is caring for a patient with a terminal illness. What would be the purpose for convening a patient care conference ? A-to agree on when care begins B-To coordinate schedules C-To determine what assessment data to put in a report D-To coordinate all aspects of the patients care

D-To coordinate all aspects of the patients care

eMAR

Electronic medication administration record

Clinical Pathway

an multidisciplinary tool that identifies a standard plan for a specific patient population

Audit

Review of a health care facility by an agency or outside group to determine whether that facility id providing and documenting certain standards of care.

HIPAA

The Health Insurance Portability and Accountability Act

Batch Charting

Waiting until the end of the shift or until all patients have been assessed to document findings from all of them.