Chapter 19: Documenting and Reporting

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."

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?

"I will arrange access for you to review the record after you put your request in writing."

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

Legal document

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

Remind the UAP about clients right to privacy

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?

SOAP charting

A new graduate is working at a first job. Which statement is most important for the new nurse to follow?

Use abbreviations approved by the facility.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

limiting abbreviations to those approved for use by the institution.

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?

"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse?

I will have to review th policy that determines proceedure is in place for client access.

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?

identifying risks and ensuring future safety for clients

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document

The nurse cared for a client admitted with uncontrolled hypertension. The client suffered a stroke shortly after the nurse's shift ended. Which information will determine if the nurse is liable?

Omitting documentation of blood pressure at the end of the shift

The nurse is documenting a progress note that relates to a client's health problem. What form of documentation is the nurse writing?

SOAP note

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?

Subjective data should be included when documenting.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed.

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."

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."

At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use?

2015

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?

A client who is home bound and needs skilled nusing care

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 the inforation can be given to the parent

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

Clip boards with client data must not leave the unit

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?

Create an addendum with a correction.

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

Which statement is not true regarding a medication administration record (MAR)?

If the client declines the dose, the nurse does not have to document this on the MAR.

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.

The nurse is caring for a client who is experiencing hypotension. The nurse is concerned about the significant drop in the client's blood pressure and decides to contact the client's health care provider. When preparing a report for the health care provider using the SBAR format, what will the nurse include? Select all that apply.

The client's blood pressure trend over the past 24 hours. The primary reason the client was admitted to the hospital. Objective and subjective data from the most recent assessment. An explanation of what is needed to improve the hypotensive state.

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment?

The lower extremities

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

clients have teh right to copy there health recoreds

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?

incident report