Ch.4: Documentation and Interprofessioal Communication
A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?
Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.
A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document?
Decreased range of motion in right shoulder
A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Repeating the measurement with a different sphygmomanometer and stethoscope
Mistakes in charting can be costly to both the client and nurse. The Joint Commission has listed a primary cause for these mistakes as a failure in communication. Life-threatening errors in health care have been labeled as which of the following:
Sentinel events
A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following?
Subjective data and objective data
While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding?
"Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm."
Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline."
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry?
"Patient complaining of abdominal pain rated 8/10."
The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear."
A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered? Select all that apply.
- A description of a large bruise on the client's thigh - The client's weight - The presence of a lump in the client's breast discovered on palpation
The hospital where a nurse works is converting from a paper-based documentation system to a computer-based one. The nurse recognizes that which of the following are advantages of computer-based over paper-based systems? Select all that apply.
- Elimination of redundant data collection by other health care team members - Increased likelihood that clients will receive life-saving treatment - Potential lowered risk of hospital-acquired infections - Ability to link the client's health record to other documents
The nursing instructor is teaching about the importance of good communication and accuracy when documenting on the client chart. Some things that are high-risk errors in documentation are the following: (Check all that apply.)
- Performing an inadequate admission assessment - Failing to record changes in a client's condition - Charting in advance - Falsifying client records
A nurse is in the elevator at the hospital. The nurse overhears another nurse laughing and making jokes about a client. Why is this situation a breach of confidentiality?
All client information is private and confidential
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use?
An assessment flow chart
A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?
Ask the other nurse to read back what first nurse reported
Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?
Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10
A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?
Cued or checklist forms
A client is having frequent blood pressure and blood glucose measurements to regulate an insulin infusion. Which type of documentation should the nurse use for this data?
Flow sheet
A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data?
Focused assessment form
On reviewing a client's database following a physical examination, a nurse realizes that the client's weight has been steadily increasing over her past three visits. What follow-up question would be best for the nurse to pose to the client based on this finding?
Has your diet or exercise changed significantly in the past year?
The nursing manager explains to the nurses that it is important for the clients to be able to access their own medical records and the new electronic health record system will provide that opportunity. The nurse would identify which of the reasons this is so important?
Health care providers can receive significant incentive payments
There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many health care providers questioning the rationale for this change in practice. What potential advantage of EHRs should administrators cite?
Improved continuity of care
A hospital is revising the policies and procedures surrounding documentation in an effort to align practices with the Health Information Technology for Economic and Clinical Health (HITECH) Act. How can the requirements of this legislation best be met?
Increase the use of electronic health records (EHRs) in the hospital.
What statement about batch charting is most accurate?
It contributes to many potential errors.
The nurse manager is implementing walking client rounds for the change-of-shift reports. One benefit of this type of reporting over others is:
It facilitates active participation of clients.
A group of nursing students is reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes?
It provides a chronologic source of client assessment data.
A health care agency has been asked to compensate a client as per a lawsuit filed against it for not following the Health Insurance Portability and Accountability Act (HIPAA) regulations. Which of the following situations is a HIPAA violation?
Not informing a client in writing of the purpose of sharing his or her personal details.
What is the name of the information program mandated by the federal government for the initial and ongoing assessment of Medicare and Medicaid clients in the homecare setting?
OASIS
A client's pain has become increasingly severe, but the client has received the maximum doses of analgesics. The nurse is receiving a new analgesic order from the health care provider. How would the nurse best validate the new order?
Read the order back to the health care provider for confirmation.
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?
SBAR
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 nursing implementing?
SOAP charting
A novice nurse is preparing for a physical examination of a client with neurological issues. The nurse takes a copy of the practice's standard assessment form and heads to the examination room, where the client is already waiting. A senior nurse notes the novice nurse's actions and says, "Here, use this form instead; it's an assessment form specifically for the neurological system." This second form is an example of which type of form?
Specialty area assessment form
After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information as which of the following?
Subjective data and objective data
A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?
The laboratory assistant can only retrieve medical records but cannot view the details.
What is an appropriate guideline for the nurse to follow when documenting assessment findings on a client?
Use phrases instead of sentences to record data
A client who had a mastectomy is being discharged home on postoperative day 1. Knowing that the client lives alone, which data would be most important for the nurse to validate for this client?
What support systems are in place to assist the client
In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed
focused
What information concerning a client's respirations should the nurse record after completing a general physical assessment?
rate, rhythm, and depth of respirations taken for a full minute
A nurse is recording some vital signs in a 12-year-old girl's chart when the girl asks why the nurse is writing all that information down. Which of the following should the nurse mention to this client as reasons for documenting assessment findings? Select all that apply.
- To prevent delays in carrying out the plan of care - To determine the educational needs of the client
Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?
A client has ask a nurse if he can read the documentation that his physician wrote in his chart.
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
It provides quick access to abnormal findings.
A nurse is caring for a client who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called:
charting by exception
During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?
"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."
A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation?
A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight
While the nurse performs the initial assessment, the client states "This is my first hospitalization and I have had no previous surgeries." How would the nurse document this information?
Client denies prior hospitalizations and surgeries
The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes
A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?
Focused
A nurse receives lab results on a client that show that the client is pregnant. The client says that this is impossible, however, because she is still breastfeeding her 1-year-old son. Which of the following would be appropriate ways for the nurse to validate the positive finding for pregnancy? Select all that apply.
Have the client take a different pregnancy test
When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason?
It becomes the foundation for the entire nursing process.
A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?
Progress notes
The nurse uses the SBAR model when reporting on clients at the change of shift. This type of report incorporates what part of the nursing process?
assessment