NUR 139 Chapter 15

Which of the following statements by the student nurse demonstrates understanding of the appropriate way to document an error in her charting?

"If I make an error, I draw a single line through it and put my initials by it."

the federally initiated goal of computer-based personal records would likely produce which of the following benefits? select all that apply

Access to records outside of the patient's home facility Increased accuracy of treatment for the patient outside their home facility Easier access to data for research Greater accuracy and improved patient care

The patient states, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today." His arms are folded across his chest. His brow is furrowed and he refuses to allow his morning vital sign measurements. Which of the following should be included in the nurse's charting? Select all that apply.

Arms are folded across his chest and brow is furrowed States, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today." Refuses to allow morning vital sign measurements

the patient record is utilized for many purposes. which of the following might be uses for the patient record

Education of student nurses Reimbursement for services Research Education for medical students

what organization audits charts regularly

Joint Commission on Accreditation of Healthcare Organizations

what dual purpose does an audit serve

Quality assurance and reimbursement

Charting in which the nurse writes a progress note that relates to one health problem is a:

SOAP note

which of the following should the nurse include in his/her charting? select all that apply

The nursing assistant reports the patient's breath smelled of alcohol. The patient was overheard telling his family about more bleeding than he has reported to his physician. The incision is oozing a small amount of red blood. The patient's pupils are dilated.

what ensures continuity of care

communication

the highest standard for maintaining a patient's condition is

confidentiality

When the nurse recognizes that he has documented one patient's assessment data on the wrong patient's medical record, the nurse should

draw a single line through the error and initial it

which of the following flow sheets provides the reader with information on an ongoing record of fluid loss?

intake and output sheet

A concise document that provides most of the patient's nursing and medical information is a(n):

kardex

besides being an instrument of continuous patient care, the patient's medical record also serves as a(n)

legal document

A nurse in a nursing home is writing a note on a resident that addresses the care the resident has received during the day and the resident's response to care. What type of note does this represent?

narrative note

The nurse is caring for a patient with uncontrolled hypertension. His blood pressure has remained controlled for the nurse's shift. At two-hour intervals the blood pressure was checked by the nurse and found to be essentially the same. The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the patient has a stroke. Years later, the patient files a lawsuit blaming the hospital for his stroke. The nurse who was caring for the patient when his blood pressure was stable cannot recall the exact blood pressure she obtained, but remembers it was normal. Will this recollection suffice in court and why?

no, if the blood pressure measurement was not documented, it did not happen

The nurse is caring for an elderly resident in a long-term care facility. The patient is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which of the following should the nurse record in his charting? Select all that apply.

patient is crying patient states, "i dont want to live anymore. I am a burden of everyone. I dont feel like doing anything at all. I dont even want to get up today."

which of the following principles should guide the nurse's documentation or entries on the patient's medical record

precise measurements are preferred over approximations

how can a nurse obtain additional information about a patient

read the patient's history and assessment

a nurse is working as a case manager, and in this role she audits charts. audits of patient records are performed primarily for quality assurance and

reimbursement

the sharing of information about a patient is

reporting

a hospital is switching to computerized charting. the nurse recognizes that one advantage to an electronic patient chart is that

retrieval of information is more efficient

during a patient's hospitalization, he has developed shortness of breath, with edema. what action should the nurse take?

revise the plan of care

how can the nurse researcher obtain information from a patient record?

study patient records

the nurse is interviewing a newly admitted patient. quoting statements made by the patient will help in maintaining

subjectivity

what activity in charting will assist most in the avoidance or errors

timeliness

a new graduate is working her first job. which of the following statements is most important for the new nurse to follow?

use abbreviations approved by the facility

which of the following describe best practices for charting? select all that apply.

use only approved abbreviations. use partial sentences and phrases

a patient's record can be more accurate if the nurse

uses point-of-care documentation