Learning Unit 2 | PrepU | Chapter 9 | Recording and Reporting

Which documentation tool will the nurse use to record the client's vital signs every 4 hours? acuity charting forms a 24-hour fluid balance record a medication record a flow sheet

a flow sheet

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: reporting. a referral. conferring. a consultation.

a referral.

Besides being an instrument of continuous client care, the client's health care record also serves as a(an): Kardex. legal document. incident report. assessment tool.

legal document.

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal? FOCUS charting charting by exception SOAP notes narrative notes

narrative notes

The parents of a hospitalized 10-year-old 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." "Are you questioning the care of your child?" "No, the health care provider will not give you access to review the records." "Only the client has the right to review the health care records."

"I will arrange access for you to review the record after you put your request in writing."

Which practice should the nurse adopt when commmunicating and documenting electronically? Avoid using client names if emailing information on an unencrypted network Avoiding using names of health care providers Include precise measurements in documentation rather than approximations Seek client permission before posting information on social media

Include precise measurements in documentation rather than approximations

Which information would the nurse be unable to locate in the client care summary or Kardex? Activity status Code status IV therapy Respiratory assessment

Respiratory assessment

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? Objective data are what the client states about the problem. The plan includes interventions, evaluation, and response. Subjective data should be included when documenting. Abnormal laboratory values are common items that are documented.

Subjective data should be included when documenting.

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry? "Client is guarding the abdomen and occasionally moaning." "Client has a history of recent abdominal pain." "Client is reporting abdominal pain is rated at 8/10." "2 mg hydromorphone hydrochloride PO was administered with good effect."

"Client is reporting abdominal pain is rated at 8/10."

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply. "I will draw a straight line through any blank space." "I will write, print, or type information legibly." "I will use only agency-approved abbreviations." "I will elaborate on the details on my entry in the clients' records." "I will stay logged in on the computer until the end of my shift."

"I will draw a straight line through any blank space." "I will write, print, or type information legibly." "I will use only agency-approved abbreviations."

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." "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."

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

The nurse is on a committee at an agency that has the task of identifying a need related to a new electronic health record (EHR) and providing supporting baseline data. In the System Development Lifecycle, what is this phase called? Test Evaluate Analyze and Plan Desire and Build

Analyze and Plan

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

Communication

A hospital client has expressed dissatisfaction with the quantity and quality of care that they have been receiving since admission. The client has told the nurse that they would like to read their medical record. How should the nurse best respond to the request? Inform the client of the need to generate a request through a lawyer. Grant the client access to the health record in accordance with the hospital's policies. Present the client's request to the hospital's ethics committee. Give the health record to the client and ask the client to return it to the nurses' station when they are done.

Grant the client access to the health record in accordance with the hospital's policies.

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

A client has asked a nurse if he can read the documentation that his health care provider wrote in his chart.

After educating a group of nursing students about the health care record and its purposes, the instructor determines that the group needs additional instruction when the students state: "Health care records are primarily used for communication among nurses and health care providers." "The record provides a means for decisions about reimbursement for care." "The health care record can serve as a resource for conducting research." "The health care record provides valuable information about a client's assessment."

"Health care records are primarily used for communication among nurses and health care providers."

Which actions should the nurse take to ensure that client information remains confidential? Select all that apply. Exit the client's room when called on the hospital-issued cell phone about another client on the team. Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. Print client information to a printer shared with another unit. Access client information on the portable computer in the hallway where visitors are present. Verify the number in the fax machine as correct prior to transmission.

Exit the client's room when called on the hospital-issued cell phone about another client on the team. Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. Verify the number in the fax machine as correct prior to transmission.

A nurse is transfusing multiple units of packed red blood cells. 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 am calling because the client receiving blood has developed dyspnea and had crackles." "This client has a medical history of heart failure." "I think the client would benefit from intravenous furosemide." "It seems like this client has fluid volume overload."

"I think the client would benefit from intravenous furosemide."

A nurse has administered six units of insulin to the client as per order. What is the safest documentation of this information? six u of insulin administered 6 units of insulin administered six U of insulin administered 6U of insulin administered

6 units of insulin administered

A nurse organizes client data using the SOAP format. Which information would be recorded under "S" of this acronym? client history client interventions client reports of pain client's chief report

client reports of pain

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

have the right to copy their health records.

Which are appropriate actions for protecting clients' identities? Select all that apply. Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Ensure that clients' names on charts are visible to the public. Orient computer screens toward the public view. Have conversations about clients in private places where they cannot be overheard.

Document all personnel who have accessed a client's record Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.

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

Write a narrative note in the designated nursing section.

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 gives clients the right to withhold the release of their information to anyone. 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. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems 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 emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

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

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

The nurse gives a change-of-shift report to the oncoming nurse. What vital information should the nurse include in the report? Select all that apply. Pain level is currently a 3 following administration of intravenous morphine. Mrs. B. Johnson is in Room 564, admitted postoperatively for an open cholecystectomy. The client has a clean and dry abdominal dressing. The client has two dogs at home; the client's spouse is taking care of the dogs. The client's hobby is photography, which we had a conversation about. No new labs have been ordered after surgery.

Mrs. B. Johnson is in Room 564, admitted postoperatively for an open cholecystectomy. No new labs have been ordered after surgery. The client has a clean and dry abdominal dressing. Pain level is currently a 3 following administration of intravenous morphine.

An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate? "It refers to the use of the electronic health record." "It combines nursing science with information management and analytical sciences." "It involves working primarily with computers and programming codes." "It is a specialty that deals with online client educational programs."

"It combines nursing science with information management and analytical sciences."

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 an obstruction to research and education." "I can share the clients' medical records with the health care team." "The clients' medical records provide data for legal evidence." "The clients' health records should be used to promote reimbursement from insurance companies"

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

The nurse charted the administration of preparation for a colonoscopy in the AM in the progress notes of the client's paper chart, pictured above. Which correct documentation guidelines did the nurse follow? Select all that apply. Acknowledge the client's response to the medication Sign every entry Identify the day and time for each entry Document in chronological order Leave blanks in the charting

Acknowledge the client's response to the medication Sign every entry Identify the day and time for each entry Document in chronological order

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? Contact information technology (IT) staff to make the correction. Contact the health care provider. Immediately delete the incorrect documentation. Create an notation with a correction.

Create an notation with a correction.

Which practice should the nurse adopt when commmunicating and documenting electronically? Seek client permission before posting information on social media Include precise measurements in documentation rather than approximations Avoid using client names if emailing information on an unencrypted network Avoiding using names of health care providers

Include precise measurements in documentation rather than approximations

A concise document that provides most of the client's nursing and medical information is a(n): past chart. office record. Kardex. nursing care plan.

Kardex.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? Omitting clients' responses to nursing interventions Documenting clients' health histories and discharge planning Identifying nursing diagnoses or clients' needs Recording nursing interventions

Omitting clients' responses to nursing interventions

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? SOAP MAR PIE SBAR

SBAR

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

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

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

limiting abbreviations to those approved for use by the institution.

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

urine output 100 ml

In SBAR, what does R stand for? Response Reinforcing data Recommendations Report

Recommendations

The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes? Suggest to the nurse manager that an in-service on abbreviation use would be helpful. Contact the facility's information technology department to delete abbreviations. Correct the abbreviations in the EHR. Ask another nurse to fix the abbreviations

Suggest to the nurse manager that an in-service on abbreviation use would be helpful.

Which is not a purpose of the client care record? To serve as a legal document To assist with care planning To serve as a contract with the client To facilitate reimbursement

To serve as a contract with the client

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. 2Fever, possible urinary tract infection 3"I don't feel well. I've been urinating often, and it burns when I urinate." 4Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

1. "I don't feel well. I've been urinating often, and it burns when I urinate." 2. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. 3. Fever, possible urinary tract infection 4. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor

Which is true of collaborative pathways? Incorporate the care plan into the progress notes Are also called critical pathways or care maps Only allow recording of significant findings in the notes Focus on the client's problems, strengths, and needs

Are also called critical pathways or care maps

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? Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." Client states expecting some pain, but it is more severe than anticipated. Client is requesting pain medications, is grimacing, and is diaphoretic. Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants.

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 on a medical unit that uses focused charting to document client care. Which written statement by the nurse demonstrates the use of focused charting to document the client assessment? The client rates abdominal pain at 8/10. The client reports feeling well all morning. The client is accompanied by family members. The client was received into care at 0730 hr.

The client rates abdominal pain at 8/10.

A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message? The laboratory assistant does not have the correct access number. The laboratory assistant can only retrieve client records but cannot view the details. The laboratory assistant is trying to view archived data. The laboratory assistant does not have the correct password.

The laboratory assistant can only retrieve client records but cannot view the details.

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? Do not release any information to the insurance company. Refer the insurance agency directly to the client. Release the full medical record to expedite payment. Use minimum disclosure policy to release the information.

Use minimum disclosure policy to release the information.

Which strategy would provide the most effective form of change of shift report? Utilizing a reporting form and allowing time for any questions. Providing the oncoming nurse the client's clipboard prior to leaving the unit. Recording the report for the oncoming shift prior to leaving the unit. Discussing the client's visitors and complaints during the prior shift.

Utilizing a reporting form and allowing time for any questions.

Which part of the client's record is commonly used to document specific client variables, such as vital signs? flow sheets critical paths progress notes nursing notes

flow sheets

A nurse at a community-health centre is completing an audit of patient records. The outcomes of this project will serve what purposes? education and confidentiality communication and evaluation quality assurance and reimbursement knowledge and advocacy

quality assurance and reimbursement

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

subjectivity

Which are examples of breaches of client confidentiality? Select all that apply. A nurse uses a computer to document a client's response to pain medication. A nurse discusses information about a client with a coworker in the elevator. A nurse shares his or her computer password with another nurse who was unable to log in to the system. A nurse updates the employer of a client regarding the client's date of return to work. A nurse checks the health record of a client to see who is the contact person for an emergency.

A nurse discusses information about a client with a coworker in the elevator. A nurse shares his or her computer password with another nurse who was unable to log in to the system. A nurse updates the employer of a client regarding the client's date of return to work.

Which note includes all elements of a SOAP note? Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess. 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. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. 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.

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.

Which example may illustrate a breach of confidentiality and security of client information? The nurse provides information over the phone to the client's family member who lives in a neighboring state. The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell. The nurse provides information to a professional caregiver involved in the care of the client.

The nurse provides information over the phone to the client's family member who lives in a neighboring state.