TLB-Chapter 19: Documenting and Reporting

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? FOCUS charting SOAP charting PIE charting narrative charting

SOAP charting Explanation: 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.

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? Immediately delete the incorrect documentation. Create an addendum with a correction. Contact information technology (IT) staff to make the correction. Contact the health care provider.

Create an addendum with a correction. Explanation: If the nurse is using an EMR and the documentation cannot be changed, an addendum will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies. The health care provider does not need to be contacted to make a correction, but does need to be informed if this caused any direct harm or effects to the client.

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 documents assessments on separate forms. It records progress under problems, intervention, and evaluation. It provides and refers to a client's problem by a number. It provides quick access to abnormal findings.

It provides quick access to abnormal findings. Explanation: Charting by exception (CBE) provides quick access to abnormal findings, as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the bestresponse by the nurse? "Legal policy requires nursing practice to be permanently integrated into the client record." "It would be easier to do it that way. You could develop a tool to use." "The facility requires us to document client care this way because of the computer application used." "The electronic health record we use does not allow us to use different formats."

"Legal policy requires nursing practice to be permanently integrated into the client record." Explanation: Legal policy requires nursing care documentation to be permanently integrated into the client record. Computer applications and electronic health record formats may have some differences, but they all use an integrated record. Suggesting that the nurse develope a new tool would be inappropriate, as separate nursing documentation would not be legal.

Which finding from a nursing audit reflects high standards for client safety and institutional health care? The nurse records inappropriate nursing interventions. The nurse fails to identify the nursing diagnoses or clients' needs. The nurse documents clients' responses to nursing interventions. The nurse fails to adequately complete data on clients' health histories and discharge planning.

The nurse documents clients' responses to nursing interventions. Explanation: Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by The Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health histories and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation.

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 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.

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 legally defensible charting? Ensure that the client's name appears on all pages. Leave spaces between entries and signature. Use abbreviations wherever possible. Record all facts and subjective interpretations.

Ensure that the client's name appears on all pages. Explanation: The nurse should ensure that the client's name appears on all pages to ensure legally defensible charting. The nurse should not leave spaces between entries and signature so that the document is legally acceptable. The nurse should use only abbreviations approved by the facility, and should not use abbreviations wherever possible. The nurse should record all the facts, but not any subjective interpretations, to ensure that the document is legal evidence.

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.

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.