Chapter 10: Documentation, Electronic Health Records, and Reporting

Which attributes are important in nursing documentation? (Select all that apply.) a. Inconsequentiality b. Timeliness c. Relevancy d. Accuracy e. Factual basis

Answers: b, c, d, e Documentation should be completed in a timely manner, be relevant and concise, and be accurate and factual. Inconsequentiality suggests a lack of importance, and documentation is an important part of patient care and nursing responsibility.

Which are reasons that accurate documentation in the medical record is important? (Select all that apply.) a. Reimbursement for care b. Evidence of care provided c. Communication between health care providers d. Nonlegal documentation of a nurse's actions e. Promotion of continuity of care

Answers: a, b, c, e Documentation in the medical record is important for reimbursement for care, for providing a record of services, for communication between providers, and for promoting continuity of care. The record is a legal document, not a non-legal document.

You notice a nursing staff member from another unit, not involved in your patient's care, is reading the chart of one of your patients. The first thing you will do is a. ignore. This staff member has a hospital ID badge. b. tell the patient that someone from off the unit was reading his record. c. ask the attending physician if this person is allowed to read the record. d. inform this staff person that the medical record is only available for staff involved in the patient's care with a legitimate need for information.

ANS: D The confidentiality of patient information must be safeguarded and the information shared only with individuals who have a need and a right to know. Nurses have a professional and legal obligation to protect patient information.

A patient requests a copy of his medical record. What is the correct response by the nurse? a. Inform him that his record is the property of the facility and cannot be accessed by anyone but staff. b. Tell him that the Code for Nurses does not allow you to give him access to his records. c. Acknowledge that he has the right to have a copy his records, and make arrangements per facility policy. d. Refer his request to the hospital administrator since all such requests need to go through proper channels.

Answer: c As part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and updated in 2009 in The American Recovery and Reinvestment Act (ARRA), patients' rights include obtaining, viewing, or updating a copy of their own medical records. Usually an EHR copy is sent to the patient within 30 days. Facilities can charge the patient for the cost incurred in copying and sending medical records. Methods for implementation vary by facility and type of medical record. The Code for Nurses does not control who has access to medical records. Requests would go through the medical records department, or whoever is responsible for obtaining and copying patient records.

What is an advantage of the use of paper medical records? a. Charts with paper records are always available to all health care team members. b. Paper records do not need much storage space in the health care facility. c. Recording on paper does not require any special computer knowledge. d. Writing implements are always available on nursing units and patient rooms.

Answer: c No special computer or information technology knowledge is needed to record on a paper medical record. Paper charts are available to only one health care team member at a time. Paper records require a lot of storage space, or have to be scanned into an electronic record to reduce storage space. There is no guarantee that a pen will be available on a nursing unit or in a patient room.

The impact of computerized provider order entry (CPOE) on the medical record has been a. increased legibility of orders. b. the need for unit secretaries to transcribe orders. c. an increase in medication errors. d. better billing practices.

ANS: A CPOE allows clinicians to enter orders in a computer that are sent directly to the appropriate department.

Charting by exception (CBE) means a. all normal patient activities are documented. b. standardized terminologies are not used in documentation. c. abnormal patient responses are highlighted. d. all patient care is considered "normal."

ANS: C Charting by exception (CBE) is documentation that records only abnormal or significant data. It reduces charting time by assuming certain norms. For this type of charting, each facility must define what is normal. Any assessment finding outside normal is charted as an exception.

A patient's sister comes to visit and asks to read the patient's chart. What is the best response by the nurse? a. Settle her in a chair at the nurses' station and give her the chart. b. Respond that the contents of a patient's chart are private and confidential. c. Tell her she can read the chart only if the patient sits with her. d. Distract the sister by changing the subject and then walking away.

Answer: b Without special permission from the patient, only those with a need-to-know-the-information-for-care reasons have access to the medical record. The patient has a legal right to control access to personal information, and the nurse should not give the sister the chart for review, even with the patient present. It is best to be honest and explain the patient's legal rights rather than avoiding the subject.

Which statement best contributes to the nurse's documentation of assessment of patient status in the patient's medical chart? a. "Patient had a good day with minimal complaints. Patient was pleasant and cooperative during morning care." b. "Patient complained that the nurse didn't come quickly enough when she pressed the call button." c. "Patient complained of pain 7 of 10 at 7:45 a.m. Received pain medication at 8 a.m., reporting pain 3 of 10 at 8:30 a.m." d. "Patient was grumpy today, even after administration of pain medication, a back massage, and a nap."

Answer: c This entry is concise, complete, and objective. It gives exact times, pain levels, and nursing interventions performed. Using terms like good or grumpy are subjective judgments or opinions and should be avoided. Stating a patient complaint would be okay if it listed specific times of occurrence, nursing assessment performed, and the nursing interventions performed to correct the issue.

Access to an electronic health record is controlled a. through assignment of individual passwords and verify codes that identify the person who has the right to enter the record. b. by the physician. c. by the nurse. d. by the patient's family.

ANS: A Access to an EHR is controlled through assignment of individual passwords and verification codes that identify people who have the right to enter the record. Passwords should never be shared with anyone. Health care information systems have the ability to track who uses the system and which records are accessed. These organizational tools contribute to the protection of personal health information.

Requirements for nursing documentation do not include a. nursing opinions of the patient's needs. b. accurate, timely, and relevant information. c. all medications administered or withheld. d. nursing diagnoses and interventions.

ANS: A General principles of medical record documentation from the Centers for Medicare and Medicaid Services (2010) include the need for completeness and legibility; the reasons for each patient encounter, including assessments and diagnosis; and the plan of care, the patient's progress, and any changes in diagnosis and treatment. They do not require nursing opinions.

You find a patient on the floor beside his bed. After doing an assessment and ensuring that the patient is safe and not injured, the next thing you do is a. complete an incident report. b. determine that since no injury occurred no further documentation is necessary. c. ask your nursing assistant to complete an incident report. d. call the risk manager.

ANS: A When an unusual and unexpected event involving a patient, visitor, or staff member occurs, an incident report is completed. An incident may be the occurrence of a fall, a medication error, or an equipment malfunction. The purpose of this report is to document the details of the incident immediately to ensure accuracy.

Medical record documentation is important because (Select all that apply.) a. it improves communication between providers. b. it is the record of care provided. c. the record becomes a legal document. d. it is where the nurse records his or her thoughts and feelings about the patient.

ANS: A, B, C The medical record is a document with comprehensive information about a patient's health care encounter, as well as demographic, administrative, and clinical data. The record serves as the major communication tool between staff members and as a single data access point for everyone involved in the patient's care. It is a legal document that must meet guidelines for completeness, accuracy, timeliness, accessibility, and authenticity.

Legal issues related to medical records include: (Select all that apply.) a. The medical record is the legal documentation of care provided to a patient. b. In the event of litigation, the medical record is often the only available evidence of an event in question. c. Medical record documentation should be based strictly on facts, not opinions. d. Medical record entries can be altered or erased to increase accuracy.

ANS: A, B, C The medical record is the legal documentation of care provided to a patient. In the event of litigation, the medical record is often the only available evidence of the event in question. Medical record documentation should be based on fact, not opinions. Every note in a medical record must include a date, time, and signature with credentials. Ethical practice dictates that nurses document only interventions that are performed. Medical record entries cannot be altered or obliterated.

The basic guideline used for nursing documentation is a. HIPAA. b. the Code of Ethics. c. the Nursing process (assessment, diagnosis, planning, implementation, and evaluation). d. the patient's diagnosis.

ANS: C The ANA's model for high-quality nursing documentation reflects the nursing process.

Your experience with an EHR has shown that the outcomes of its use include a. decreased communication between health care providers. b. the potential for greater numbers of medication errors. c. decreased productivity. d. a decrease in the duplication of diagnostic tests.

ANS: D The electronic health record (EHR) includes documentation over time from inpatient and outpatient sources. Laboratory data and other test results are available in inpatient and outpatient settings so that care decisions can be made. Adoption of an EHR system produces major cost savings through gains in productivity and error reduction, which ultimately improves patient health status.

What is a purpose of a hand-off report? a. Ensures continuity of care and patient safety b. Keeps the doctor informed c. Completed when a patient is discharged to his home d. Determines patient assignments

Answer: a A handoff report shares patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety. The handoff report is usually shared among direct caregivers. Doctors are kept informed verbally by the nurse, through SBAR reporting, and by accessing the EHR. A patient being discharged to home is given discharge instructions but is not being "handed off" to another caregiver, so a handoff report is not appropriate. Patient assignments are determined before a handoff report is needed and are based on patient acuity, staffing, and a number of other factors.

Which note is an example of the S in SBAR? a. Patient resting; pain was rated 3 of 10 1 hour after receiving narcotic analgesic. b. Patient was admitted on evening shift with a fractured right femur after a fall at home. c. Patient's pain was rated 8 of 10 before administration of narcotic pain medication. d. Assess pain ever 2 hours, continue pain medication as prescribed, and provide backrub.

Answer: a The S in SBAR stands for situation. In this case, the patient is resting, and the pain is rated 3 of 10 one hour after receiving a narcotic analgesic. Describing the admission reason and time provides the background (B). Assessment (A) of this patient revealed pain rated 8 of 10 before giving pain medication. The nurse's recommendation (R) is that pain should be assessed every 2 hours and that pain medications should be given as prescribed.

When should administered medications be documented? a. At the end of a shift when all meds have been given b. As given to avoid the possibility of double dosing c. After every meal to document at least three times daily d. In pencil to allow for changes to be made

Answer: b All medications and nursing care should be documented as it is completed to ensure that documentation occurs in a timely manner. Documentation should occur as soon as possible after assessment, interventions (including medication administration), condition changes, or evaluation. Documentation only at the end of a shift or after meals would not be timely and could lead to medication errors and fragmented care. Nursing documentation is a legal record and is done electronically or in ink so that it cannot be changed. Errors are corrected in a specific way depending on the type of charting, but the original documentation would still be accessible.

This hospital has just implemented the use of electronic health records (EHRs). While learning to use this new system, the nurse realizes that EHRs may do which of the following? a. Limit access to the patient record to one person at a time b. Improve access to client information at the point of care c. Negate the use of nursing documentation d. Increase the potential for medication errors

Answer: b Use of EHRs can improve access to patients' information. An unlimited number of people at a time can access a patient's medical record. Nursing documentation is an essential part of nursing care, whether it is completed on paper or electronically. The potential for medication errors decreases when electronic medication administration records are used.