Taylor's Chapter 16: Documenting, Reporting, Conferring, and Using Informatics (Prep U)

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 instructor is discussing a nursing student's social media post about an interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is most appropriate?

"Any information that can identify a person is considered a breach of client privacy."

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."

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 report at the bedside. Which response by the nurse receiving report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care."

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."

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.

What ensures continuity of care?

Communication

What is the primary purpose of the client record?

Communication

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

Documentation

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

Nutritional consult

Which principle should guide the nurse's documentation of entries on the client's health care record?

Precise measurements should be used rather than approximations.

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

The nursing is caring for a client who requests to see a copy of his or her health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records

How can the nurse researcher obtain information from a client record?

Study client records.

Which strategy could be implemented by the nurse in ensuring the protection of electronic data at healthcare agencies?

The nurse locks out client information, except to those who have been authorized through appropriate security measures.

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows what is important when working with a client translator?

Translators may need additional explanations of medical terms

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

The goal of computer-based patient records would likely produce which benefits? Select all that apply.

access to records outside of the client's home facility increased acccuracy of treatment for the client outside their home facility easier access to data for research greater accuracy and improved client care

The nurse is documenting care for a client with diabetes. Which nursing documentation will The Joint Commission review? Select all that apply.

nursing care provided physical assessment nursing diagnoses client teaching

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting

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."

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 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.

Which statements by the nurse demonstrate understanding of the appropriate way to document an error in charting?

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

A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis?

public health department Notifying the public health department of communicable disease is considered an exemption for beneficial disclosure.

The nurse is tasked to organize weekly care plan conferences with other health care team members. What does the nurse communicate are the purposes of this meeting? Select all that apply.

rehabilitation plan from the physical therapist and if changes need to be made review of client's current progress in the plan of care discussion of the diabetic client's meal plan addressing the need for durable medical equipment when the client goes home

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."

During hospitalization, the client has developed shortness of breath, with edema. What action should the nurse take?

Revise the plan of care A plan of care should be generated at admission and revised to reflect changes in the client's condition.

Which statement regarding FOCUS charting is most accurate?

The charting focuses on client strengths, problems, or needs.

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

The lower extremities Peripheral vascular disease mostly affects the lower extremities

A nursing student is attending a clinical rotation in a labor/deliver/postpartum unit and is able to see a vaginal delivery for the first time. The student takes a picture of the newborn and posts it on a social mediat website. What action may occur related to this privacy violation?

The student may be dismissed from the nursing program as well as fined for a HIPAA violation.

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

omitting client's response to nursing interventions

Which charting formats permit documentation on any significant topic, not just client problems?

FOCUS FOCUS charting permits documentation on any significant topic. It is organized around data, action, and response.

The nurse hears an unlicensed assitive personel (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.

A nurse documents hypertension in a woman who is 5 months pregnant and then writes a narrative describing the situation. This type of abnormal status can be seen immediately with narrative easily retrieved in what documentation format?

Charting by exception

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 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.

An area of specialization in nursing that is a combination of computer science, information science, and nursing science is termed:

Informatics

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.

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 Data aggregation is a process that involves data collection, analysis, use, reporting, and delivery of feedback throughout the organization. Organizations will use process and outcomes data to measure what they achieve for clients and population-based communities. Population health management technology performs data mining, risk stratification, and analysis. Searches can be conducted for disease trends, diagnoses, procedures, and missed appointments.

What does the nurse recognize as purposes of the electronic health record? Select all that apply.

documenting continuity of care qualifying healthcare providers for government funds ensuring client safety facilitating health education and research

The client record is utilized for many purposes. Which might be uses for the client record? Select all that apply.

education of student nurses reimbursement for services research education for medical students

The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? Select all that apply.

Documentation must be kept of personnel who have accessed a client's record. Light boxes for examining X-rays with the client's name must be in private areas. Conversations about clients must take place in private places where they cannot be overheard

A nurse is preparing a seminar on the uses of documentation in client records. Which topics should the nurse include in the seminar? Select all that apply.

Quality improvement Research Decision Analysis Financial reimbursement

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 manager overhears a nurse say, "I'm not going to fill out an incident report because it will be used against me." What response by the nurse manager is most appropriate?

"The main purpose of an incident report is for quality improvement, not disciplinary action."

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

1600: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. 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.

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

A flow sheet A flow sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special

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 in to 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?

Attach a copy of the incident report to the chart.

When documenting client care, what principles of documentation is the nurse responsible for? Select all that apply.

Confidentiality Accuracy Objective Timely The principles of proper documentation include confidentiality, accuracy, completeness, concise, objective, organized, timely, and legibility.

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?

Ensure that the client's name appears on all pages.

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

A nurse is documenting the effectiveness of a client's pain management on the client record. Which documentation is written correctly?

Mr. Gray reports that on a scale of 0 to 10, the pain he is experiencing is a 3.

To improve communication within the health care system, tools were created to standardize the process and assist with clarity and conciseness. SBAR is one such tool. In this tool, what does R stand for?

Recommendations SBAR stands for Situation, Background, Assessment, and Recommendations.

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. he plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care providers' judgment of the situation, and abnormal lab values would be included in objective data.

Which organization audits charts regularly?

The Joint Commission

The nurse is providing documentation for the care rendered to clients. Which characteristics identify documentation as effective? Select all that apply.

The documentation is readible The documentation is thoughtful The documentation is timely The documentation is clear, concise, and complete Characteristics of effective documentation include accessible, accurate, relevant, consistent, auditable, clear, concise, and complete, legible/readable, thoughtful, timely, contemporaneous, and sequential, and retrievable on a permanent basis.

Question 20 See full question 11s Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

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

Time Dose Reason given Effectiveness of medication The nurse should document the medication given, time, route, dose, reason given, and effectiveness of the medication on the medication administration record. The vital signs would be included on a different part of the chart.

A new graduate is working at a first job. Which statement is most important for the new nurse to follow?

Use abbreviations approved by the facility.

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

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

To which Health Insurance Portability and Accountability Act regulation should the nurse adhere when safeguarding clients' written, spoken, and electronic information?

submitting a written notice to all clients identifying the uses and disclosures of their health information

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.

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 incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members.

A nurse is giving change of shift report on a client who has just returned from surgery. What client information should the nurse include in the report? Select all that apply.

name of the client intake and output prior to surgery client discharge teaching needs current vital signs

A nurse is transfusing multiple units of packed red blood cells (PRBCs). 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 client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?

Accurately documenting client care on the client record

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.

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

If the client refuses the dose you don't have to document this on the MAR. If a client refuses a dose, it is important to circle that dose and write a note as to why you did not administer it.

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.

A nurse manager of a health care provider's office is responsible for obtaining signed authorizations for releasing client information to third parties. In which situations would it not be necessary for the nurse to obtain an authorization from the cltient? Select all that apply

Reporting the incidence of an infectious disease to Centers for Disease Control and Prevention Releasing a medical record to the court when a nurse is being sued for negligence Facilitating organ donation of a deceased client Providing statistics related to the use of a dangerous piece of equipment

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 The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

A nurse is documenting care for an older adult client who is recovering from a mild stroke. Which documentation entries follow the recommended guidelines for communicating and documenting client information? Select all that apply.

The client rates pain as 2 compared to a 7 yesterday. Vital signs returned to normal. Radial pulse 72, strong and regular

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

interpretation of data. Stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement.

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and:

reimbursement Audits of client records serve a dual purpose: quality assurance and reimbursement.

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 refuses. The nurse's refusal is based on the understanding that which people would be entitled to access of the client's records?

those directly involved in the client's care

A nursing student asks a nurse why nurses cannot document in a separate record instead of the client record in order to document and find the information needed. What is the best response by the nurse?

Legal policy requires nursing practice to be permanently integrated into the client record."