CH 19 - Documenting

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? A. progress notes B. plan of care C. problem list D. data base

A. progress notes

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation? A. Charting by exception B. Source-oriented C. PIE charting D. Problem-oriented

B. Source-oriented

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: A. using only those abbreviations that are defined in full at another location in the client's chart. B. limiting abbreviations to those approved for use by the institution. C. ensuring that abbreviations are understandable to clients who may seek access to their health records. D. using only abbreviations whose meaning is self-evident to an educated health professional.

B. limiting abbreviations to those approved for use by the institution.

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 best response by the nurse? A. "The facility requires us to document client care this way because of the computer application used." B. "The electronic health record we use does not allow us to use different formats." C. "Legal policy requires nursing practice to be permanently integrated into the client record." D. "It would be easier to do it that way. You could develop a tool to use."

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

Which is the proper way to document midnight in a client's record? A. 1200 B. 2401 C. 0000 D. 1201

C. 0000

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? A. Clinical judgment B. Accreditation C. Documentation D. Psychomotor skills

C. Documentation

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? A. SOAP B. MAR C. SBAR D. PIE

C. SBAR

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate? A. "You can get an electronic printout of client lab data to take with you." B. "Be sure to write down specific information for your clinical paperwork." C. "Be sure to put the client's name and room number on all paperwork." D. "Clipboards with client data should not leave the unit."

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

Which charting format permits documentation on any significant topic, not just client problems? A. CBE B. SOAP C. PIE D. FOCUS

D. FOCUS

Which principle should guide the nurse's documentation of entries on the client's health care record? A. Nurses should not refer to the names of physicians. B. Correcting fluid is used rather than erasing errors. C. Documentation does not include photographs. D. Precise measurements should be used rather than approximations.

D. Precise measurements should be used rather than approximations.

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? A. narrative charting B. FOCUS charting C. PIE charting D. SOAP charting

D. SOAP charting

Which organization audits charts regularly? A. National League for Nursing B. American Nurses Association C. Sigma Theta Tau International D. The Joint Commission

D. The Joint Commission

Two types of personal health records (PHRs)

Standalone personal health records: Patients fill in information from their own records; the information is stored on patients' computers or the Internet. Tethered/connected personal health records: Linked to a specific health care organization's electronic health record (EHR) system or to a health plan's information system.

Variance report

incident report

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. A. current orders B. what the client watched on television during the shift C. any abnormal occurrences with the client during the shift D. what time the nurse will return for the next shift E. identifying demographics, including diagnosis

A, C, E

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? A. Submitting a written notice to all clients identifying the uses and disclosures of their health information B. Disclosing client health information for research purposes after obtaining permission from the client's physician C. Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information D. Releasing the client's entire health record when only portions of the information are needed

A. Submitting a written notice to all clients identifying the uses and disclosures of their health information

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? A. protecting the nurse and the hospital from litigation B. identifying risks and ensuring future safety for clients C. following up the incident with other members of the care team D. gauging the nurse's professional performance over time

B. identifying risks and ensuring future safety for clients

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? A. The client is receiving sufficient relief from pain medication, stating no pain in either knee. B. The client appears to have a low tolerance for pain and frequently reports intense pain. C. The client reports that on a scale of 0 to 10, the current pain is a 3. D. The client appears comfortable and is resting adequately and appears to not be in acute distress.

C. The client reports that on a scale of 0 to 10, the current pain is a 3.

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? A. Nurse's shift report B. Telemedicine report C. Transfer report D. Incident report

D. Incident report

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: A. relevant data. B. factual statement. C. important information. D. interpretation of data.

D. interpretation of data.

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? A. health care professionals of the facility B. close friends of the client C. any family member of the client D. those directly involved in the client's care

D. those directly involved in the client's care

Source-oriented record

documentation system in which each health care group records data on its own separate form

Problem-oriented medical record (POMR)

documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes

PIE charting

documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P)-intervention (I)-evaluation (E) format, and evaluated each shift

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: A. are required to obtain health record information through their insurance company. B. can be punished for violating guidelines. C. need to obtain legal representation to update their health records. D. have the right to copy their health records.

D. have the right to copy their health records.

SOAP format

method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P)

Charting by Exception (CBE)

shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes