Chapter 20- Documenting and Reporting

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 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." "I've documented all the care, including the vital signs." "The client reports dizziness when walking."

"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."

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." "No, the health care provider will not give you access to review the records." "Are you questioning the care of your child?" "Only the client has the right to review the health care records."

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

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? "The hospital owns your records and does not have to allow you access while you are a client here." "You may not understand all of the information and it will confuse you so I will help you decipher it all." "I will have to review the policy that determines what procedure is in place for client access." "Let me open up the computer access so that you can see what information is of interest to you."

"I will have to review the policy that determines what procedure is in place for client access."

The nurse is caring for a client who has been physically restrained. Which observation(s) will the nurse include when documenting the client's care? Select all that apply. The client's blood pressure is 135/82 mm Hg. The client has redness around the ankles bilaterally. The client participates in range-of-motion exercises. The client's skin turgor is normal. The client exhibits agitation and shouts at the nurse.

(ALL) The client exhibits agitation and shouts at the nurse. The client's blood pressure is 135/82 mm Hg. The client's skin turgor is normal. The client has redness around the ankles bilaterally. The client participates in range-of-motion exercises.

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: Some facilities do not require them on their plans of care. Although not written, the nurse must know or question the rationale before performing an action. The use of rationales is not commonly practiced in the clinical setting. Rationales are only important while the nurse is in training. The rationale is deleted to provide additional charting space in the computer system.

Although not written, the nurse must know or question the rationale before performing an action.

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." Client states expecting some pain, but it is more severe than anticipated. Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. Client is requesting pain medications, is grimacing, and is diaphoretic.

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

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? Contact information technology (IT) staff to make the correction. Contact the health care provider. Immediately delete the incorrect documentation. Create an notation with a correction.

Create an notation with a correction.

Which practice should the nurse adopt when commmunicating and documenting electronically? Avoid using client names if emailing information on an unencrypted network Avoiding using names of health care providers Include precise measurements in documentation rather than approximations Seek client permission before posting information on social media

Include precise measurements in documentation rather than approximations

A new nursing graduate is working at a first job. When completing client documentation, the nurse should perform which action? Only use abbreviations approved by the facility. Use PIE charting, even if it is not the institution's specified charting method. Avoid using client names in EHR entries Only document changes in the client's status.

Only use abbreviations approved by the facility.

At change of shirt, the nurse is presenting information about a client to a colleague that is coming on shift. The nurse is performing what nursing action? Reporting Dialogue Documentation Verification

Reporting

Which statement regarding FOCUS charting is most accurate? The charting focuses on client strengths, problems, or needs. Each note should include each section of the data, action, response (DAR) format of charting. The charting focuses on the injury or illness only. Problem, intervention, evaluation (PIE) charting is used with FOCUS charting.

The charting focuses on client strengths, problems, or needs.

The following statement is documented in a client's health record: "Client c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? The client has symptoms in the morning associated with a heart attack. The client is coughing and experiencing severe heartburn in the morning. The client has a history of severe complaints in the morning. The client reports waking up this morning with a severe headache.

The client reports waking up this morning with a severe headache.

Which finding from a nursing audit reflects high standards for client safety and institutional health care? The nurse records inappropriate nursing interventions. The nurse fails to identify the nursing diagnoses or clients' needs. The nurse documents clients' responses to nursing interventions. The nurse fails to adequately complete data on clients' health histories and discharge planning.

The nurse documents clients' responses to nursing interventions.

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation? charting by exception SOAP focus narrative

charting by exception

In SBAR, what does R stand for? Reinforcing data Response Recommendations Report

Recommendations

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." "The CABG procedure will help identify nutritional needs." "A complete ablation of the biliary growth will decrease liver inflammation." "The CABG procedure will help increase intestinal motility and prevent constipation."

"A coronary artery bypass graft will benefit your heart."

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? "The electronic health record we use does not allow us to use different formats." "Legal policy requires nursing practice to be permanently integrated into the client record." "The facility requires us to document client care this way because of the computer application used." "It would be easier to do it that way. You could develop a tool to use."

"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? "Let me get that for you." "Only authorized persons are allowed to access client records." "The provider will need to give permission for you to review." "I am sorry I can't access that information."

"Only authorized persons are allowed to access client records."

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 1 bottle of glucose One U of glucose 1U of glucose

1 Unit of glucose

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 information can be given to the parent. Provide the information to the parent. Explain the reasons for the hospitalization, but give no further information. Take the parent to the client's room and have the client give the requested information.

Ask the client if information can be given to the parent.

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? Clinical judgment Documentation Psychomotor skills Accreditation

Documentation

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. Call the pharmacy to have the order entered in the electronic record. Write the order in the client's record. Add the new order to the medication administration record.

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

he 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. Access the health care record at the bedside and show the client how to navigate the electronic health record. Discuss how the hospital can be fined for allowing clients to view their health care records. Explain that only a paper copy of the health care record can be viewed by the client.

Review the hospital's process for allowing clients to view their health care records.

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? FOCUS charting SOAP charting PIE charting narrative charting

SOAP charting

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 client appears to have a low tolerance for pain and frequently reports intense pain. The client appears comfortable and is resting adequately and appears to not be in acute distress. The client is receiving sufficient relief from pain medication, stating no pain in either knee.

The client reports that on a scale of 0 to 10, the current pain is a 3.

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? Write a narrative note in the designated nursing section. Place the narrative note chronologically after the respiratory therapist's note. Review the laboratory results under the health care provider section. Use a critical pathway to document the physical assessment.

Write a narrative note in the designated nursing section.

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 protecting the nurse and the hospital from litigation following up the incident with other members of the care team gauging the nurse's professional performance over time

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): Kardex. legal document. assessment tool. incident report.

legal document.

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? pain rating of 4 on a scale of 0-10 describes wound as itchy urine output 100 ml concerned with feeling tired

urine output 100 ml

Which are appropriate actions for protecting clients' identities? Select all that apply. 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. Orient computer screens toward the public view. Document all personnel who have accessed a client's record. Ensure that clients' names on charts are visible to the public.

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.

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin." "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." "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." "I am calling about the client in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin."

"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)? The MAR distinguishes between routine and "as needed" medications. If the client declines the dose, the nurse does not have to document this on the MAR. The MAR identifies routine times for medication administration. After using an electronic MAR, the nurse should log off.

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

The nurse is caring for a client who is prescribed a pain medication by mouth every 4 to 6 hours. When assessing pain status, the client states not wanting to take any medication right now. Which principle should the nurse consider when documenting interventions regarding medication administration for this client? Steps taken to encourage the client to comply should be documented along with assessment findings. The client's pain should be documented on a scale of 0 to 10 when documenting the administration of pain medication. Medication that is not administered should be documented along with the reason. Medication should be documented along with the time and the amount given or not given each time medication is scheduled to be administered.

Medication that is not administered should be documented along with the reason. Correct response:

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 gives clients the right to withhold the release of their information to anyone. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Problem-oriented recording has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care.

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply. S: The nurse handling the transfer describes the client situation to the new nurse. S: The nurse discusses the client's symptoms with the new nurse in charge. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse explains the rules of the new facility to the client. R: The nurse gives recommendations for future care to the new nurse in charge.

S: The nurse handling the transfer describes the client situation to the new nurse. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse gives recommendations for future care to the new nurse in charge.

A nurse is documenting care for clients in a hospital setting. Which documenting errors may potentially increase the nurse's risk for legal problems? Select all that apply. -The content includes descriptions of situations that are out of the ordinary. -The content is not in accordance with professional standards. -The content reflects client needs. -The documentation is not countersigned. -Dates and times of entries are omitted. -There are lines between the entries.

The content is not in accordance with professional standards. There are lines between the entries. Dates and times of entries are omitted.

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. a consultation. conferring. reporting.

a referral.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? reimbursement subjectivity organization objectivity

subjectivity

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 any family member of the client close friends of the client health care professionals of the facility

those directly involved in the client's care