Chapter 19: Documenting and reporting
A client is scheduled for a CABG procedure. What information should the nurse provide to the client?
"A coronary artery bypass graft will benefit your heart" 459
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." 477
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" 457
The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states:
Although not written, the nurse must know or question the rationale before performing an action
Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing?
Nutritional consult 478
Which abbreviation is correct for use in documentation?
PO 460
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?
SBAR 232
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 469
The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?
Subjectivity 469
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:
interpretation of data 456
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" 457
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 homebound and needs skilled nursing care
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. 471
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 475
Which example may illustrate a breach of confidentiality and security of client information?
The nurse provides information over the phone to the client's family member who lives in the neighboring state 455
A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator?
Translators may need additional explanations of medical terms 479
A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate?
"Any information that can identify a person is considered a breach of client privacy" 455
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?" 477
A nurse manager of a health care provider's office is responsible for obtaining signed authorizations for releasing client information to third parties. In which situations would it not be necessary for the nurse to obtain an authorization from the cltient? Select all that apply.
-Reporting the incidence of an infectious disease to Centers for Disease Control and Prevention -Releasing a medical record to the court when a nurse is being sued for negligence -Facilitating organ donation of a deceased client -Providing statistics related to the use of a dangerous piece of equipment 457
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." In the SOAP format, "S" refers to subjective data, which are usually recorded as the client's statement or anything verbalized by the client. 468
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 456
An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate?
Explain the reason why information cannot be disclosed 455
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 478
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 453-454
Which principle should guide the nurse's documentation of entries on the client's health care record?
Precise measurements should be used rather than approximations 456
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?
Progress notes 468
When the home care nurse visits a client, who is recently widowed, the nurse finds that the home is cluttered with trash. The client appears sad and disheveled. Which action would the nurse take based on the assessment findings?
Refer to the health care provider 583
The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate?
Review the hospital's process for allowing clients to view their health care records 463
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 0-10, the current pain is a 3 191
The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?
The nurse meets with nurses or other health care professionals to discuss some aspect of client care 479
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 457
Which documentation tool will the nurse use to record the client's vital signs every 4 hours?
a flow sheet 471
A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of:
a referral 478
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 475
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 client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. 466
A nurse is giving a verbal report to a health care provider using the ISBAR communication technique. The client being discussed has signs and symptoms of fluid volume deficit. Which statements should the nurse include in the report? Select all that apply.
-"I am the nurse assigned to the client." -"The client reports dizziness when walking." -"The client vomited twice and has dry mucous membranes." -"Current blood pressure is 90/50 mm Hg with a pulse of 112 bpm." -"All of the orders have been completed." 474
The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply.
-"I will write, print, or type information legibly." -"I will use only agency-approved abbreviations." -"I will draw a straight line through any blank space." 456
Which are appropriate actions for protecting clients' identities? Select all that apply.
-Document all personnel who have accessed a client's record. -Place light boxes for examining X-rays with the client's name in private areas. -Have conversations about clients in private places where they cannot be overheard. 458
A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information?
1 Unit of glucose 456
A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents?
Client's record and occurrence report 478
Which is the primary purpose of client records?
Communication 463
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 478
Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?
Omitting clients' responses to nursing interventions 468
The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?
Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. 468
The nurse hears an unlicensed assitive personel (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 the client's right to privacy. The nurse should first remind the UAP about the client's right to privacy. All other actions are appropriate, but do not immediately protect the client's privacy. 455
The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?
Reporting 474
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 The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. 469
The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?
Urine output 100ml Objective data, such as the measurable urine output, are collected by the nurse. Subjective data, such as feeling pain, itchiness, or fatigue, are reported by the client. 469
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 In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. 456
A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?
Problem-orientated method The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care. 468
The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply.
-Showing the provider the trends from baseline to present in blood pressure -Informing the provider of the client's present heart rate of 116 beats/min -Faxing the results of blood chemistry levels to the provider's office 474
A nurse is working with the case management model and using a collaborative pathway. The nurse notes that the client has not met an expected outcome and documents this using occurrence charting. When completing this documentation, what information would the nurse include? Select all that apply.
-Unexpected event -Cause of the event -Actions taken in response to the event 470
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.
-any abnormal occurrences with the client during the shift -identifying demographics, including diagnosis -current orders 475
The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given?
2130
The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr. The client is NPO and has received morphine sulfate 4 mg IV for pain with a decrease of epigastric pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method?
4/10 pain on pain scale, epigastric pain; with reports of nausea Charting by exception charts only that which falls outside the standard of care and norms 469-470
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?
It provides quick access to abnormal findings 469