Chapter 19, Documenting, Reporting, Conferring

What is the primary purpose of an incident report?

Means of identifying risks

A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)?

Minimum data set

A nurse in a nursing home is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent?

Narrative note

The nurse managers of a home health care 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 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?

"Client complaining of abdominal pain rated at 8/10."

A nurse is documenting the intensity of a client's pain. What would be the most accurate entry?

"Client states pain is a 9 on a scale of 1 to 10."

Which of the following data entries follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry?

A. Jones, RN

It's hard to be in bed and ask for help. You ring for a nurse who never seems to help."

A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse?

May be up as desired

A physician's order reads "up ad lib." What does this mean in terms of client activity?

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as ...

Avelox (moxifloxacin) 400 mg daily

Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse?

Charting by exception

A nurse organizes client data using the SOAP format. Which of the following would be recorded under "S" of this acronym?

Client complaints of pain

What is the nurse's best defense if a client alleges nursing negligence?

Client's record

A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports?

Come prepared with material required to take notes.

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation?

Cross out the incorrect statement with a single line.

A nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to nursing?

Data, information, knowledge

What part of the client's record is commonly used to document specific client variables, such as vital signs?

Graphic record

A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next?

Individualize it to the specific client.

A nurse caring for a client who is being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation?

Information is documented in separate forms by each health care personnel.

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document?

Intervention carried out

A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called?

Nursing care rounds

A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as the first step?

Problem selected

Which one of the following methods of documentation is organized around client diagnoses rather than around patient information?

Problem-oriented medical record (POMR)

In what type of documentation method would a nurse document narrative notes in a nursing section?

Source-oriented record

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which of the following would be most appropriate for the nurse to do?

Strike out the entry with a single line, place initials next to it, and write the correct entry.

ISBAR

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the health care provider?

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which of the following?

The physician's assessment and treatment

What activity in charting will assist most in the avoidance of errors?

Timeliness

Which of the following abbreviations is on the list of the Joint Commission do not use abbreviations? Select all that apply.

U (unit,QD (daily),> (greater than)

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks?

Vulnerability to legal liability since nurse's safe, routine care is not recorded

The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which of the following clinical situations?

When communicating a client's change in condition to the client's physician

A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client confidentiality?

Writing the client's name on the student care plan