Taylor Chapter 20 - Documenting and Reporting PrepU

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."

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." SBAR refers to: S (situation): what is the situation you are calling about?; B (background): pertinent background information related to the situation; A (assessment): what is your assessment of the situation?; R (recommendation):

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."

A nurse administrator is participating in an audit that has the goal of creating a quality improvement plan. Which organization will the nurse be reporting to?

the Joint Comission

what requirements must be met by a patient for home care Medicare reimbursement?

the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.

what is the documenting procedure for a patient that declines/refuses a medication?

the nurse should circle that dose and write a note as to why the nurse did not administer it

what is consultation?

the process of inviting another professional to evaluate the client and make recommendations about treatment

what is referring?

the process of sending or guiding the patient to another source for assistance

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

what is conferring?

to consult with someone to exchange ideas or seek information, advice, or instructions

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

urine output 100 ml Objective data, such as the measurable urine output, are collected by the nurse. Subjective data, such as feeling pain, itchiness, or fatigue, are reported by the client.

can MARs distinguish between routine and "as needed" medications?

yes

should the nurse report the presence of IV fluids and the presence of any advanced directives during verbal handoff summary?

yes

what is reporting?

oral, written, or computer-based communication of client data to others

At change of shirt, the nurse is presenting information about a client to a colleague that is coming on shift. The nurse is performing what nursing action?

Reporting

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

The nurse documents clients' responses to nursing interventions

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse?

"I will have to review the policy that determines what procedure is in place for client access."

what is SBAR used for?

The nurse should use SBAR (situation, background, assessment, recommendation) when communicating with the health care provider.

what abbreviation is correct for use in documentation when stating that something is per os or by mouth?

PO

The following statement is documented in a client's health record: "Client 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 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 documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error?

create a notation with a correction If the nurse is using an EMR and the documentation cannot be changed, an notation will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed.

what must happen for anyone outside the interdisciplinary healthcare team who is directly involved in client care to review health records?

express formal permission from the patient

what are the ways that reporting to primary care provider can occur?

face-to-face, by telephone, by text messaging, or, in some settings (e.g., long-term or home care), by fax

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 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."

what does the P stand for the in SOAP format?

Plan

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

0000

what are SOAP and PIE notes used for?

SOAP and PIE are nursing notes in the medical record

what does the A stand for in the SOAP format?

assessment

why should the nurse include the current assessment of the client in the verbal handoff summary?

it enables the receiving nurse to prepare for the client before arrival. It also allows the receiving nurse to clarify any information that may appear on the written handoff form.

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 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 health care provider tells the client, "You are experiencing an MI," and leaves the room. The client asks the nurse what an MI stands for. What response by the nurse is most accurate?

myocardial infarction

what does the O stand for in the SOAP format?

objective data - factual observations during assessment

what does S stand for in the SOAP format?

subjective data - what the client says

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

subjectivity

The nurse receives a verbal prescription from a health care provider during an emergency situation. Which action(s) should be taken by the nurse? Select all that apply.

-Read back the prescription. -Record the date and time of the prescription. -Include V.O. with the health care provider's name on the prescription.

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

do patients have the right to see their own medical records?

-Clients have the right to see their own medical records and request changes to documentation that may be in error. -make sure you're following the policy outlined by the facility in which you are practicing

Which are appropriate actions for protecting clients' identities? Select all that apply.

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

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 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.

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." The statement about pain secondary to postoperative status and increased activity reflect the "A," or assessment, portion of the SOAP format.

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation

what shows evidence of quality care as stipulated by the Joint Commission?

Documenting clients' responses to nursing interventions is correct

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 Providing insurance coverage does not negate the privacy laws

Which practice should the nurse adopt when commmunicating and documenting electronically?

Include precise measurements in documentation rather than approximations

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.

A client will be transferred from the cardiovascular intensive care unit to the telemetry unit for continued care. Which documentation correctly demonstrates how the nurse would prepare information to be conveyed to the receiving nurse during a verbal handoff report?

Mr. Alfred Jones, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes.

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 emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

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 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.

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

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. Providing information over the phone to a family member without knowing whether or not the client wants that family member to know the information is a breach of confidentiality and security of client information.

when is the only time verbal orders from a provider can be accepted?

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 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

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

a legal document

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