NUR 290 ch. 16: Documentation and Communication in the Healthcare Team

Which is the proper way to document midnight in a client's record?

0000

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client?

0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.

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

Which are examples of breaches of client confidentiality? Select all that apply.

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 action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions

Which abbreviation is correct for use in documentation?

PO

What information should the nurse document in the medication record when administering a non-narcotic pain medication? Select all that apply.

Reason given Time Effectiveness of medication Dose

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?

SOAP charting

A nurse is documenting care for clients in a hospital setting. Which documenting errors may potentially increase the nurse's risk for legal problems? Select all that apply.

The content is not in accordance with professional standards. There are lines between the entries. Dates and times of entries are omitted.

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?

Use minimum disclosure policy to release the information.

The client is admitted to the hospital for a surgical procedure and has gone through several areas of the hospital in one day. Nurses have been providing care and charting about the condition of the client throughout the day. When would the nurse chart a progress note about the client? Select all that apply.

When admitting the client to the surgical admissions unit When receiving the client postoperatively on the surgical floor When the surgical procedure is performed

What is the primary purpose of an incident report?

means of identifying risks

In SBAR, what does R stand for?

recommendations

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 declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?

those directly involved in the client's care

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

urine output 100 ml

A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality?

writing the client's name on the student care plan

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 reporting that her abdominal pain is rated at 8/10."

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."

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

When documenting client care, which principles should the nurse strive for? Select all that apply.

Confidentiality Accuracy Objectivity Timeliness

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment?

The client reports that on a scale of 0 to 10, the current pain is a 3.

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

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate?

"The benefit of CBE is less time needed on computer charting."

Which statement is not true regarding a medication administration record (MAR)?

If the client declines the dose, the nurse does not have to document this on the MAR.

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?

The client reports waking up this morning with a severe headache.

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 can only retrieve patient records but cannot view the details.

A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which is an example of a written form of communication?

checklist

What is the primary purpose of the client record?

communication

Documentation and Communication in the Healthcare Team

have the right to copy their health records.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data

A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology?

Telemedicine and mobile technology

Which data entry follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

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."

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. Have conversations about clients in private places where they cannot be overheard.

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?

SBAR

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?

a client who is homebound and needs skilled nursing care

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

a flow sheet

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

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

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

it provides quick access to abnormal findings

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

limiting abbreviations to those approved for use by the institution.

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:

referral