Chapter 26 Documentation and Informatics

A registered nurse is teaching a group of student nurses about legal guidelines for the effective recording of a patient's data on a handwritten paper document. Which statement of the student nurse needs correction?

"I should leave spaces with unknown information blank." The nurse should not leave blank spaces while recording the patient's health information because another person may add incorrect information in the blank spaces. The nurse should draw a horizontal line in the space with his or her signature at the end to avoid this potential issue. The nurse should avoid using generalized, empty phrases such as "had a good day," which does not provide any information. Errors should not be erased, as it may indicate that the nurse is hiding some evidence. Errors should be scratched out with a single line, and the nurse should sign and date it. Black ink is more legible when records are photocopied or scanned, and illegible entries may lead to misinterpretations. Text Reference pg. 351

Which of the following charting entries is most accurate?

Client walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise. The answer that describes the client's actions and heart rate before and after exercise provides the most accurate, objective information for the chart . Text Reference - p. 350

A nurse caring for a client on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this client is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system?

Clinical decision support system A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user. Text Reference - p. 360

You are supervising a beginning nursing student who is documenting client care. Which of the following actions requires you to intervene? The nursing student:

Documented medication given by another nursing student. Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed

A nurse checks the urine output of a client following a renal transplant every 2 hours. Which is the appropriate place to document results in the client's chart?

Flow sheet A flow sheet is utilized when repeated observations are to be recorded in a quick and accurate manner. The information from a flow sheet is retrieved quickly, too. An admission sheet is used to record the detailed initial assessment at the time of admission. An operative report records the summary of the client's surgery, complications, and preoperative and postoperative diagnoses. The physician's order sheet contains the information of the physician's orders for treatment and medications with date, time, and signature. Text Reference - p. 355

At the end of a shift, a nurse documents a client's condition, anticipated condition, medications, and nursing interventions fulfilled, so that the next nurse can follow the appropriate treatment and care for the client. What is this kind of report referred to as?

Hands- off report Hand-off reports are prepared when client care is transferred from one caregiver to another in the health care setting at any time. The report prepared during a shift change is also a hand-off report. A discharge summary is the summary of the client's hospital stay, condition at discharge, diagnosis, prognosis, and treatment plan and goals. An incident report records any incident happening that is inconsistent with the routine care of a client or with the routine operation of a health care unit, such as a fall or injury from medical equipment. A telephone report is made when the nurse reports any significant changes in the client's health condition to the health care provider or other medical personnel. Text Reference - p. 357

The nurse faxes a client's medical record to an unknown number. Which law is the nurse violating?

Health Insurance Portability and Accountability Act (HIPAA) HIPAA protects the client's privacy for health information and governs the management of client information. Illegal exchange of the client's health information violates this act. ARRA encourages electronic communication among the health care bodies and mandates all medical records to be kept electronically from 2014. HITECH rewards the primary health care provider and facilities that adopt the electronic medical record (EMR)/electronic health record (EHR). The TJC act does not exist. Text Reference pg. 349

A client asks for a copy of her medical record. The best response by the nurse is to:

Indicate that she has the right to read her record. Clients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the client has given permission. Text Reference - p. 349

When updating a client's chart, a nurse erroneously documents a wrong medication. Upon realizing the mistake, what does the nurse do?

Strike with a single line, tag it as an error, put initials, and document the correct medication. If an error occurs during documentation of the client's health information, the nurse puts a straight single line through it, tags it with the word "error," and initials and dates it. The nurse does not apply correction fluid or scratch out the error. The nurse need not rewrite the entire client's chart due to this error. This would be a time-consuming process. Rewriting the entire chart may lead to forgetting about elements of care, which may lead to erroneous documentation. Text Reference p. 351

As you enter the client's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the client's emotional status?

The client stated that he felt frustrated by the lack of information he received regarding his tests. "The client stated that he felt frustrated by the lack of information he received regarding his tests" is a nonjudgmental statement regarding the nurse's observations about the client. Statements about the client being "defiant" or "demanding" are judgmental, and information in the medical record should be factual and nonjudgmental. The statement about the client appearing to be "upset" needs to be more specific regarding the reason for the client's concern. Text Reference - p. 350

A client was shifted from the intensive care unit to the cardiac unit. What kind of reports are used to communicate between the two units?

Transfer reports Transfer reports are the types of hand-off reports used when clients are transferred from one unit to another. Referrals are made when the client requires the services provided by another caregiver for a different category of health needs. Shift change reports are reports handed over during the shift change between nursing staff. A discharge summary is a report format used on discharge of the client. It contains the client's discharge diagnosis, prognosis, and treatment plan. Text Reference - p. 357

You are helping to design a new client discharge teaching sheet that will go home with clients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet?

You need to use words the clients can understand when writing the directions. Clients need to be able to understand information that you provide to them; ensure that written instructions are provided at a level that matches the clients' reading ability. Text reference pg. 356