PREP U CHAPTER 19 Fundamentals
The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation? SOAP charting by exception narrative focus
charting by exception Explanation: Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. In the scenario, the BP is abnormal and is documented by exception. The other types of documentation are not being represented in this scenario.
What ensures continuity of care? critical thinking integration communication reassessment
communication Explanation: Communication ensures continuity of care and provides essential data for revision of. or continuation of care. The acts of reassessment, critical thinking, and integration do not contribute directly to continuity of care.
What dual purpose does an audit serve? education and confidentiality quality assurance and reimbursement communication and evaluation knowledge and quality
quality assurance and reimbursement Explanation: Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits have no role in communications, evaluation, knowledge, quality, education, or confidentiality,
Which statement about client records and documentation is correct? Clients should keep the original record at home in a fireproof safe. Communication is the primary purpose of client records. Nurses should not document progress notes in a client's record. Physicians will not review nurses' documentation in the client's record.
Communication is the primary purpose of client records. Explanation: Communication is the primary purpose of client records. Original records are kept by the facility, not the client. Nurses should document key information in the client record, and physicians review nursing documentation to help make clinical decisions.
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 SOAP PIE MAR
SBAR Explanation: The nurse should use SBAR (situation, background, assessment, recommendation) when communicating with the health care provider. SOAP and PIE are nursing notes in the medical record, and MAR is medication administration record.
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 Explanation: Client care records are legal documents, communication tools, and assessment tools. They are used for care planning, quality assurance, reimbursement, research, and education. They in no manner reflect a contract between health care staff and the client. The only exception to this is at the point of admission when the client (or responsible party) signs an acknowledgement of expenses about to be incurred as health care insurance information is obtained.
Which documentation by the nurse best supports the PIE charting system? 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 Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given
Vomiting 250 mL undigested food, antiemetic given, no further vomiting Explanation: PIE charting includes the problem, intervention, and evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (problem), antiemetic given (intervention), no further vomiting (evaluation).
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. conferring. reporting.
a referral. Explanation: Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.
The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? 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. 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.
Review the hospital's process for allowing clients to view their health care records. Explanation: The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the records.
A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and: staff development. reimbursement. research. change of mechanisms.
reimbursement. Explanation: Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits do not play a role in staff development, research, or change of mechanisms within a system.
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 Explanation: In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.
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' health records should be used to promote reimbursement from insurance companies" "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' medical records are an obstruction to research and education." Explanation: The clients' medical records are good sources of data for research and education, and, therefore, it is incorrect to say that they are an obstruction. The other statements do not need correction.
Which abbreviation is correct for use in documentation? PO Sub q Per os BT
PO Explanation: Facilities develop acceptable abbreviation lists based on guidelines from oversight agencies. PO, which is a derivative abbreviation from the Latin term "per os," signifying "orally" or "by mouth," is a commonly approved abbreviation. "Sub q" (meaning "subcutaneous"; SC is preferred), "Per os" (meaning "orally" or "by mouth"; PO is preferred), and "BT" (meaning "bedtime"; can be confused with "BID," meaning "twice daily") are not generally accepted abbreviations.
The nurse documents that a client does not have pain prior to the administration of pain medication. The client, however, requested medication for increasing postsurgical pain. What is the appropriate action to correct the pain assessment documented in the client's paper medical record? Scribble through the entry. Obtain white-out to cover the entry. Write over the entry in another color pen. Place one line through the entry and initial it.
Place one line through the entry and initial it. Explanation: The appropriate action is to place one line through the entry and initial it. Any written documentation that cannot be clearly read, or that is vague, scribbled through, whited out, written over, or erased makes for a poor legal defense.
The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? The plan includes interventions, evaluation, and response. Objective data are what the client states about the problem. Subjective data should be included when documenting. Abnormal laboratory values are common items that are documented.
Subjective data should be included when documenting. Explanation: Subjective data should be included when using the SOAP format for documentation. Objective data are what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care provider's judgment of the situation, and abnormal lab values would be included in objective data.
A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? The abdominal area The lower extremities Lung sounds Heart rate and rhythm
The lower extremities Explanation: Peripheral vascular disease mostly affects the lower extremities. While the lung sounds, heart rate and rhythm, and abdominal assessment will be important, the focused assessment should be on the lower extremities. Reference:
What does the nurse recognize as purposes of the electronic health record? Select all that apply. facilitating health education and research qualifying health care providers for government funds ensuring client safety defending health care personnel during practice lawsuits documenting continuity of care
documenting continuity of care qualifying health care providers for government funds ensuring client safety facilitating health education and research Explanation: The electronic health record provides an avenue to document continuity of care, qualify health care providers for government funds, ensure client safety, and facilitate health education and research. It can provide evidence during practice lawsuits, however, that is not the purpose of the electronic health record.
Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in charting? "If I make an error, I can draw a red circle around it." "If I make an error, I have to rewrite the entire entry." "If I make an error, I draw a single line through it and put my initials by it." "If I make an error, I use white-out on it."
"If I make an error, I draw a single line through it and put my initials by it." Explanation: When an error occurs, the nurse should draw a single line through the error and place his or her initials above it. If the nurse is using an EMR (electronic medical record), and the documentation cannot be changed - this will require an addendum.
A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines? Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth Yelling at staff members, dementia worse today, refused breakfast Inappropriate behavior during breakfast, screamed during the shower, smiled while kicking other clients Confused, belligerent, and uncooperative with care
Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth Explanation: Nursing documentation should focus on behaviors and avoid words such as better, normal, or worse. Using terms such as "inappropriate behavior" or "belligerent" is judgmental. The nurse should document only actual behaviors that the nurse witnesses.
Which principle should guide the nurse's documentation of entries on the client's health care record? Documentation does not include photographs. Nurses should not refer to the names of physicians. Precise measurements should be used rather than approximations. Correcting fluid is used rather than erasing errors.
Precise measurements should be used rather than approximations. Explanation: Precise measurements and times must be used whenever possible. It is appropriate to use the names of physicians and photographs can constitute documentation. Handwritten entries should be struck through with a single line and initialed, not covered with correcting fluid or erased.
Which organization audits charts regularly? The Joint Commission National League for Nursing American Nurses Association Sigma Theta Tau International
The Joint Commission Explanation: The Joint Commission (TJC)audits client records regularly under specific guidelines that are announced annually and shared with each institution. TJC also encourages institutions to set up ongoing quality assurance programs. The National League for Nursing, American Nurses Association, and Sigma Theta Tau International are professional nursing organizations that provide services to nurses; they do not access client records. .
The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? subjectivity objectivity organization reimbursement
subjectivity Explanation: Quoting what the client is saying helps in the documentation of subjective data. Objective data are assessment data that may be directly observed by the nurse such as blood pressure. Organization is the structure of the documentation and does not relate to subjective data. Reimbursement is a distractor that doesn't relate to assessment data.
A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? "Any information that can identify a person is considered a breach of client privacy." "You may continue to post about a client, as long as you do not use the client's name." "All aspects of clinical practice are confidential and should not be discussed." "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."
"Any information that can identify a person is considered a breach of client privacy." Explanation: Any information that can identify a person is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the facility and unit is disclosed in the post. Discussion of clinical practice can be helpful for learning purposes or seeking advice on care. No care should be discussed, even privately, with friends and family without first obtaining the client's permission.
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 that it demonstrates whether high-quality care is given." "CBE is a relatively new format of documentation in electronic health records." "The benefit of CBE is less time needed on computer charting." "CBE is the best way to protect against lawsuits."
"The benefit of CBE is less time needed on computer charting." Explanation: One of the benefits of CBE is less time needed for documentation. CBE does not always support high-quality care and is not the best way to protect against lawsuits since not all data are documented. CBE is not a new format for documentation.
The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate? -Ask the client if information can be given to the parent. -Provide the information to the parent. - Explain the reasons for the hospitalization, but give no further information. -Take the parent to the client's room and have the client give the requested information.
Ask the client if information can be given to the parent. Explanation: No information should be provided by the nurse without permission from the client. Taking the parents to the client's room to get information from the client may violate the client's privacy.
A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? Client's record and occurrence report Occurrence report and critical pathway Care plan and client's record Critical pathway and care plan
Client's record and occurrence report Explanation: An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.
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 MAR distinguishes between routine and "as needed" medications. The MAR identifies routine times for medication administration. After using an electronic MAR, the nurse should log off.
If the client declines the dose, the nurse does not have to document this on the MAR. Explanation: If a client declines a dose, the nurse should circle that dose and write a note as to why the nurse did not administer it. MARs can distinguish between routine and "as needed" medications identify routine times for medication administration. After using an electronic MAR, the nurse should log off to prevent others from inadvertently adding information about other clients to the initial client's record.
Which actions should the nurse take before making an entry in a client's record? Select all that apply. Reviewing the agency's list of approved abbreviations Checking that clients' names are not identified within the chart forms Choosing the charting format that the nurse prefers Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting
Reviewing the agency's list of approved abbreviations Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting Explanation: The nurse should review the agency's list of approved abbreviations, as each agency may use a different set of approved abbreviations and has approved its use for legally defensible reasons. The nurse should locate clients' files within an electronic health record system rather than creating a new record, to avoid duplication and missing important information in the client's record that was added previously. The nurse should identify the form appropriate to use for documenting, because some aspects of clients' care are recorded on specific forms. The nurse should use the charting format required by the facility, not choose one that the nurse prefers. The client's name should be identified on chart forms, so that if the forms become separated from the chart, the nurse will still be able to identify which client chart they belong to.
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 is receiving sufficient relief from pain medication, stating no pain in either knee. The client appears comfortable and is resting adequately and appears to not be in acute distress. The client appears to have a low tolerance for pain and frequently reports intense pain. The client reports that on a scale of 0 to 10, the current pain is a 3.
The client reports that on a scale of 0 to 10, the current pain is a 3. Explanation: The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.
Which strategy would provide the most effective form of change of shift report? 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.
Utilizing a reporting form and allowing time for any questions. Explanation: A change-of-shift report is a discussion between health care team members leaving their shift and health care team members coming on duty for the next shift. It includes a summary of each client's condition and current status of care and should be in a standardized format to ensure concise and accurate information. It is not useful to discuss the client's complaints and visitors during the prior shift. Tape recording and giving the nurse the client's clipboard doesn't allow the oncoming nurse to ask questions.
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 Explanation: An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.
The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best? "The UAP logs in under my name and documents the vital signs." "The UAP is able to log in and enter the information so all members of the health care team can see it." "Vital signs do not need to be recorded unless they are abnormal." "The UAP will tell me what the vital signs are, and I will record them in the record so the health care provider can review them."
"The UAP is able to log in and enter the information so all members of the health care team can see it." Explanation: Each person who makes entries in the client's electronic health record (EHR) is responsible for the information he or she records and can be summoned as a witness to testify concerning what has been documented. Although the licensed registered nurse has accountability, the UAP can document data that has been collected in the EHR. It is not appropriate to document for someone else, and all users should always log out of the computer prior to allowing another person to document.
A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? A never event A sentinel event An audit A variance
A variance Explanation: This scenario reflects a variance in care. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client.
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 into 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? Report the error to the primary provider. Fill out an incident report. Stop the infusion and document the time. Attach a copy of the incident report to the chart.
Attach a copy of the incident report to the chart. Explanation: For legal reasons, the nurse should not attach a copy of the incident report to the chart. The nurse should, however, stop the infusion and document the time, report the error to the primary provider and nursing supervisor, and fill out an incident report.
Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? Releasing the client's entire health record when only portions of the information are needed Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information Submitting a written notice to all clients identifying the uses and disclosures of their health information Disclosing client health information for research purposes after obtaining permission from the client's physician
Submitting a written notice to all clients identifying the uses and disclosures of their health information Explanation: Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the physician's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations.
Which strategy would provide the most effective form of change of shift report? Providing the oncoming nurse the client's clipboard prior to leaving the unit. Utilizing a reporting form and allowing time for any questions. Discussing the client's visitors and complaints during the prior shift. Recording the report for the oncoming shift prior to leaving the unit.
Utilizing a reporting form and allowing time for any questions. Explanation: A change-of-shift report is a discussion between health care team members leaving their shift and health care team members coming on duty for the next shift. It includes a summary of each client's condition and current status of care and should be in a standardized format to ensure concise and accurate information. It is not useful to discuss the client's complaints and visitors during the prior shift. Tape recording and giving the nurse the client's clipboard doesn't allow the oncoming nurse to ask questions.
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." Explanation: The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records. They may also update their health record if inaccurate, get a list of the disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations, request a restriction on certain uses or disclosures, and choose how to receive health information.
A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate? "Be sure to write down specific information for your clinical paperwork." "You can get an electronic printout of client lab data to take with you." "Clipboards with client data should not leave the unit." "Be sure to put the client's name and room number on all paperwork."
"Clipboards with client data should not leave the unit." Explanation: HIPAA has created several changes that protect client confidentiality and affect the workplace. One such change is that the names of clients on charts can no longer be visible to the public, and clipboards must obscure identifiable names of clients and private information about them. Therefore, writing down clinical information, taking the data off the unit, and including client identifiers are inappropriate.
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." "No, the physician will not give you access to review the records." "Are you questioning the care of your child?" "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." Explanation: Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. Because the child is a minor, it is the parents' right to view the client's record. Therefore, the statements about the physician not giving the parents access to review the records and asking if the parents are questioning the care of their child are incorrect.
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." Explanation: Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.
The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development? "The care plan is required for every client by The Joint Commission." "The care plan is the only way for nurses to document what they do." "The care plan provides additional documentation about the work of the nurse." "The care plan shows the medical diagnosis for the client."
"The care plan is required for every client by The Joint Commission." Explanation: The Joint Commission's standards require that the record show evidence of a plan of care. Many agencies require a separate nursing care plan as a means of demonstrating compliance. Nurses revise the plan of care as the client's condition changes. The other responses are not reflective of this standard.
The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development? "The care plan is required for every client by The Joint Commission." "The care plan provides additional documentation about the work of the nurse." "The care plan shows the medical diagnosis for the client." "The care plan is the only way for nurses to document what they do."
"The care plan is required for every client by The Joint Commission." Explanation: The Joint Commission's standards require that the record show evidence of a plan of care. Many agencies require a separate nursing care plan as a means of demonstrating compliance. Nurses revise the plan of care as the client's condition changes. The other responses are not reflective of this standard.
Which statement by the nurse is the best example of an internal communication strategy the nurse should use to discuss the use of new equipment, client care problems, and change in policies? "You will see the procedure for using the new equipment in the client assignments." "We will discuss the new policies at the change-of-shift report." "You will demonstrate the use of the cardiac monitor on the nursing rounds." "We will be having a team conference to discuss concerns that clients' relatives have raised."
"We will be having a team conference to discuss concerns that clients' relatives have raised." Explanation: Team conferences are effective communication strategies to discuss the relatives' concerns because this usually involves the multidisciplinary team and the relatives could be involved. Change-of-shift report is incorrect since this is only a summary of each client's condition and current status of care in a discussion between the personnel of the outgoing and incoming shifts. Client assignment identifies the clients for whom the staff person is responsible and describes their care and is therefore incorrect. Nursing rounds is incorrect since this strategy provides the staff the opportunity to observe and converse in the client's presence and boost the client's confidence.
The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR? "I am concerned that the client might be exhibiting sepsis." "Will you prescribe a complete blood count to check the white blood cell count and a culture?" "The client's temperature has been 102°F (38.9°C) for the last 6 hours." "The client was admitted today with a urinary tract infection."
"Will you prescribe a complete blood count to check the white blood cell count and a culture?" Explanation: SBAR is an acronym for Situation, Background, Assessment, Recommendation. Situation is what the nurse describes, the current situation. Background is the pertinent information regarding the current situation. Assessment is objective information that supports the situation. Recommendation is what the nurse recommends to the health care provider. In this case, the Recommendation is the nurse asking the provider to prescribe a complete blood count and culture. "I am concerned that the client might be exhibiting sepsis" is a situation statement. "The client's temperature has been 102°F (38.9°C) for the last 6 hours" is the assessment of the client supporting the situation. The client being admitted today with a urinary tract infection is Background.
A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. 1.Fever, possible urinary tract infection 2."I don't feel well. I've been urinating often, and it burns when I urinate." 3.Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. 4.Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago.
-"I don't feel well. I've been urinating often, and it burns when I urinate." -Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. -Fever, possible urinary tract infection -Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. Explanation: When using the SOAP format, the nurse would first document the subjective data (S: the client's complaint), objective data (O: abdomen, urine characteristics, temperature and contributing factors), assessment (A: caregiver's judgment about the situation—fever and possible urinary tract infection), and plan (P: what the caregiver is going to do—notify the physician, encourage fluids, and continue to monitor).
The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client? 8:00: Pt is resting in bed and appears to be comfortable. 0800: Resting in bed, eating some breakfast. Complains of headache. 0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. 0800: Side rails up, call light in reach. Bed in high position.
0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. Explanation: Pt is not an appropriate abbreviation for patient and it is understood that all entries are specific to the patient. Avoid the phrases "appears to be" and "seems to be," as they suggest uncertainty. Military time should be used to avoid confusion. Specific, detailed information should be included when possible, such as consumed 80% of breakfast and a reported pain level. Bed in high position is not appropriate for patient safety.
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. Explanation: Although the scientific rationale is not documented in the clinical plan, it is no less important than in the instructional plan. Nurses and other members of the healthcare team must know the rationale behind the intervention or must question and review the rationale before performing the action.
Which agency is responsible for monitoring compliance to Health Information Technology for Economic and Clinical Health (HITECH)? World Health Organization Department of Social Services The Joint Commission Centers for Medicare and Medicaid Services
Centers for Medicare and Medicaid Services Explanation: The HITECH Act was established in 2009 to create incentives for professionals and agencies to receive financial payment for the meaningful use of technology to improve client care. The Centers for Medicare and Medicaid Services is the agency responsible for monitoring compliance to HITECH. The Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States. The World Health Organization is a specialized agency of the United Nations that is concerned with international public health. There is a department of social services in each state that focuses on benefits and facilities such as education, food subsidies, health care, police, fire service, job training and subsidized housing, adoption, community management, policy research, and lobbying.
Which note includes all elements of a SOAP note? -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, 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 with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess.
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. Explanation: A SOAP note consists of subjective information, objective information, an assessment, and a plan. The correct response includes each of these while the remaining three responses are each lacking a different one of the components.
What is the primary purpose of the client record? Communication Advocacy Research Education
Communication Explanation: Patient records serve many purposes., but the ANA states that the most important of these is "communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory and legislative, reimbursement, research, and quality activities" (ANA, 2010, p. 5). Thus communication with the health care team is a more important purpose of documentation than advocacy, research, or education.
Which are appropriate actions for protecting clients' identities? Select all that apply. · Orient computer screens toward the public view. · Ensure that clients' names on charts are visible to the public. · 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.
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. Explanation: Documenting all personnel who have accessed a client's record, placing light boxes for examining X-rays with the client's name in private areas, and having conversations about clients take place in private where they cannot be overheard are useful strategies to limit casual access to the identity of clients and health informatics. Orienting computer screens toward the public view and visibly displaying clients' names on charts are incorrect, as these are breaches of patient confidentiality.
Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edematous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"? Exception PIE Narrative FOCUS
FOCUS Explanation: The nurse used FOCUS charting, as it gives priority attention to the client's current or changed behavior. PIE charting occurs when the nurse records the client's progress under the headings of problem, intervention, and evaluation. Narrative charting content resembles a log or journal entry. Charting by exception is charting only abnormal assessment findings that deviate from a standard norm. Therefore, this nurse is not demonstrating PIE, narrative, or exception charting
The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? Inform the health care provider that a written order is needed. Write the order in the client's record. Call the pharmacy to have the order entered in the electronic record. Add the new order to the medication administration record.
Inform the health care provider that a written order is needed. Explanation: Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.
A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method? Focus charting method Source-oriented method Problem-oriented method PIE charting method
Problem-oriented method Explanation: The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care. Progress notes clearly focus on client problems. Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically. PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). Focus charting method brings the focus of care back to the client and the client's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a client and client care.
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 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 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 emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Explanation: Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers is an advantage of problem-oriented recording and is therefore correct. Giving clients the right to withhold the release of their information to anyone is a beneficial disclosure and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving clients' problems among caregivers and having 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 are examples of source-oriented recording.
The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? Dialogue Documentation Reporting Verification
Reporting Explanation: Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. .Some facilities may use encrypted (protected) software programs such as Share Point or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.
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. -The client has symptoms in the morning associated with a heart attack. -The client is coughing and experiencing severe heartburn in the morning. -The client has a history of severe complaints in the morning.
The client reports waking up this morning with a severe headache. Explanation: The statement uses approved abbreviations for complains of (c/o) and headache (H/A). Therefore the statement indicates that the client is complaining of a severe headache this morning. The abbreviation c/o stands for complains of, not coughing. The abbreviation H/A stands for headache, not heart attack or heartburn.
The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? The nurse can implement care once written orders are received from the provider. The nurse can accept verbal orders to provide immediate care and record once the client is stable. The client must be stabilized before the nurse can obtain any orders from the provider. The provider can input orders remotely into the EHR system for the nurse to retrieve.
The nurse can accept verbal orders to provide immediate care and record once the client is stable. Explanation: In most agencies, the only circumstance in which the attending physician, nurse practitioner, or house office may issue orders verbally is in a medical emergency. In such a situation, the physician/nurse practitioner is present but finds it impossible to write the order due to the emergency circumstances. When a client is admitted to the unit, the prescriber writes orders either in the electronic record or on paper. Physicians/providers can insert orders remotely, but this is not the most appropriate option in an emergency. Stabilization of the client, while important, should not supersede receiving orders as the providers instructions could be integral to stabilizing the client.
Which are purposes of documentation in health care records? Select all that apply. To facilitate quality To support decision analysis To serve as a financial record To assist with clinical research To provide personal communication to the family SUBMIT ANSWER
To facilitate quality To serve as a financial record To support decision analysis To assist with clinical research Explanation: Documentation provides data to facilitate quality, serve as a financial record, assist with clinical research, and support decision analysis. Documentation does not serve to provide personal communication to the family.
A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator? Talking loudly helps the translator and the client understand the information better. It is always okay to not use a translator if a family member can do it. Talking directly to the translator facilitates the transfer of information. Translators may need additional explanations of medical terms.
Translators may need additional explanations of medical terms. Explanation: When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times.
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. Use minimum disclosure policy to release the information. Refer the insurance agency directly to the client. Release the full medical record to expedite payment.
Use minimum disclosure policy to release the information. Explanation: The nurse should use minimum disclosure policy to release the information, as per HIPAA regulations. It is inappropriate to not release any information to the insurance company, to refer the insurance agent directly to the client, and to release the full medical record to expedite payment.
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. Review the laboratory results under the physician section. Place the narrative note chronologically after the respiratory therapist's note. Write a narrative note in the designated nursing section.
Write a narrative note in the designated nursing section. Explanation: Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the physician section. Critical pathways are not used to document physical assessments.
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 Explanation: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team
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 Explanation: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team.
Besides being an instrument of continuous client care, the client's health care record also serves as a(an): -assessment tool. -legal document. - Kardex. -incident report.
legal document. Explanation: The client record serves as a legal document of the client's health status and care received. An assessment tool may be a formal document that is included as part of the client's record. A Kardex is typically an erasable, temporary document that would be shredded when no longer needed for the client's care. Incident reports are internal documents that are not a part of the client's record, and therefore not a legal document regarding their health care.
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. using only abbreviations whose meaning is self-evident to an educated health professional. ensuring that abbreviations are understandable to clients who may seek access to their health records. using only those abbreviations that are defined in full at another location in the client's chart.
limiting abbreviations to those approved for use by the institution. Explanation: In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.
