Chapter 19 Documenting
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."
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 it at the bedside. Which response by the nurse receiving the report is most appropriate?
"It will allow for us to see the client and possibly increase client participation in care."
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?
"Legal policy requires nursing practice to be permanently integrated into the client record."
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."
The nurse is documenting morning care for a client with diabetes. Which documentation is mostappropriate for this client?
0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.
A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information?
Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."
Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?
Omitting clients' responses to nursing interventions
Which organization audits charts regularly?
The Joint Commission
Which statement regarding FOCUS charting is most accurate?
The charting focuses on client strengths, problems, or needs.
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?
The client reports that on a scale of 0 to 10, the current pain is a 3.
A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?
graphic sheets
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?
indidence report
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:
interpretation of data. - should document factual data, patient is sitting in the room with shades drawn and lights out. Then others can interpret the patients actions
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?
those directly involved in the client's care