PrepU Ch. 19 Documenting and Reporting

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?

progress notes

A client is scheduled for a CABG procedure. What information should the nurse provide to the client?

"A coronary artery bypass graft will benefit your heart."

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

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 -Locating clients files within an electronic health record system -Identifying the form appropriate to be used for documenting

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.

-any abnormal occurrences with the client during the shift -identifying demographics, including diagnosis -current orders

The nurse is taking verbal medication prescriptions from the provider by hand to be documented in the clients eMAR for administration of medication. How should the nurse correctly document this information?

0800-Amoxicillin 250mg PO with water. J. Doe, RN.

Which is the primary purpose of client records?

Communication

Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing?

Nutritional consult

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?

charting by exception

Which is not a purpose of the client care record?

To serve as a contract with the client

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

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 nurse in a long-term care facility is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent?

narrative note

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.

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."

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?

Translators may need additional explanations of medical terms.

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

Omitting clients' responses to nursing interventions

At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use?

2015

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 variance

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 think the client would benefit from intravenous furosemide."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

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

A client's record can be more accurate if the nurse:

uses point-of-care documentation.

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."

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."

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

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

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

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate?

Explain the reason why information cannot be disclosed.

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?

Place one line through the entry and initial it.

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

Remind the UAP about the client's right to privacy.

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?

Subjective data should be included when documenting.

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment?

The lower extremities

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 accept verbal orders to provide immediate care and record once the client is stable.

What situation would permit the nurse to disclose information without the client's approval?

The nurse suspecting that a client is being abused or neglected

Which strategy would provide the most effective form of change of shift report?

Utilizing a reporting form and allowing time for any questions.

Which documentation by the nurse best supports the PIE charting system?

Vomiting 250 mL undigested food, antiemetic given, no further vomiting

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate?

Write a narrative note in the designated nursing section.

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

interpretation of data.

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

subjectivity

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.

-Obscuring identifiable names of clients and private information about clients on clipboards -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

The nurse is caring for an older adult resident in a long-term care facility. The client 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 or her charting? Select all that apply.

-The client is crying. -The client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today."

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). "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 temperature.

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 +"?

FOCUS

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?

Problem-oriented method

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

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

What ensures continuity of care?

communication

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 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:

Although not written, the nurse must know or question the rationale before performing an action.