Chapter 5 Documentation

The nurse discovers a client lying on the floor. Which should the nurse write when completing an incident report?

"Found client lying face down on the floor beside the bed."

The nursing instructor is reviewing documentation with a group of students. Which should the instructor include as the purpose of written documentation? Select all that apply. 1. Communicate pertinent data to the health-care team 2. Serve as a record of accountability for accreditation 3. Serve as a legal record for the health-care provider only 4. Serve as a record of accountability for quality assurance and reimbursement purposes 5. Provide a permanent record of medical and nursing diagnoses

1. Communicate pertinent data to the health-care team 2. Serve as a record of accountability for accreditation 4. Serve as a record of accountability for quality assurance and reimbursement purposes 5. Provide a permanent record of medical and nursing diagnoses

The nursing instructor is reviewing documents with a group of students. Which parts of the problem-oriented medical record should be discussed? Select all that apply. 1. Database 2. Problem list 3. Plan of care 4. Progress notes 5. Incident reports

1. Database 2. Problem list 3. Plan of care 4. Progress notes

Information about the Health Insurance Portability and Accountability Act (HIPAA) is being prepared for a group of new nurses to review during orientation. Which should be emphasized about this act? Select all that apply. 1. HIPAA guarantees a client the right to view and obtain a copy of his or her medical record. 2. HIPAA guarantees a client the right to take the original medical chart. 3. HIPAA asks a client to specify who can obtain personal health data. 4. HIPAA ensures the right of a client to amend personal health information. 5. HIPAA requires hospitals to disclose the way in which a client's health data will be used.

1. HIPAA guarantees a client the right to view and obtain a copy of his or her medical record. 3. HIPAA asks a client to specify who can obtain personal health data. 4. HIPAA ensures the right of a client to amend personal health information. 5. HIPAA requires hospitals to disclose the way in which a client's health data will be used.

The nursing instructor teaches students about source-oriented medical records. Which labeled tabs should the instructor emphasize? Select all that apply. 1. Nurse's notes 2. Care plan 3. Graphic data 4. Physician's orders 5. Rehabilitation therapy

1. Nurse's notes 3. Graphic data 4. Physician's orders 5. Rehabilitation therapy

The staff members at a hospital are preparing for a visit from The Joint Commission (TJC). Which should be explained to the staff about the purpose of this visit? Select all that apply. 1. TJC acts as an insurance company by offering reimbursement to hospitals. 2. TJC seeks to improve the safety and quality of care that health-care organizations provide to the public. 3. TJC offers accreditation when a facility practices in a manner that meets TJC standards. 4. TJC sends a team of reviewers to visit the facility and assess its policies, procedures, and actual performance. 5. TJC sets the standards by which the quality of health care is managed nationally and internationally.

2. TJC seeks to improve the safety and quality of care that health-care organizations provide to the public. 3. TJC offers accreditation when a facility practices in a manner that meets TJC standards. 4. TJC sends a team of reviewers to visit the facility and assess its policies, procedures, and actual performance. 5. TJC sets the standards by which the quality of health care is managed nationally and internationally.

A hospital's risk-management team provides the nursing staff with an in-service about incident reports. Which information should be included? Select all that apply. 1. An incident report always involves the client. 2. Incident reports are part of the client's medical record. 3. A medication error should be documented on an incident report. 4. A client, visitor, or employee injury should be documented on an incident report. 5. An incident report is used to document out-of-the-ordinary things that happen in a health-care facility.

3. A medication error should be documented on an incident report. 4. A client, visitor, or employee injury should be documented on an incident report. 5. An incident report is used to document out-of-the-ordinary things that happen in a health-care facility.

The nurse is preparing to document care provided in the client's electronic medical record. Which should the nurse keep in mind when entering the data?

Avoid using abbreviations within the note.

The nursing instructor is asked to prepare an educational program on incidents that have occurred on a specific care area. Which is the most cost-effective approach for the instructor to collect information to support the educational program?

Complete a database search through the electronic medical record.

A health-care organization is considering focus charting. Which categories are commonly documented using this approach?

Data, action, response

The nurse notices that there is no room at the end of a written note to sign the note. What should the nurse do?

Draw a line through the space on the next line and sign at the end.

A health-care facility uses narrative charting. What should the nurse remember when following this documentation approach?

It tells the client's story.

The nurse completes documentation on an electronic medical record. What should the nurse do next?

Log out of the system.

A resident is being admitted to the skilled nursing facility. Which documentation is required to be completed for this client?

Minimum data set

The nurse receives a login and password to access the electronic medical record. Where should the nurse store this information?

Place it in the wallet that is locked up during the shift.

The director of a home care agency is scheduling staff to make home visits. Which staff member should visit a client newly admitted to the agency for care?

Registered nurse

The nurse reviews pertinent laboratory data and assesses the response to pain medication. Where should the nurse write this information until able to document it in the medical record?

Report form

The nurse uses a cheat sheet to jot down pertinent client data while providing care. What should the nurse do with the sheet after documenting all client care?

Shred the paper.

The nursing instructor is reviewing the different types of charting methods with the class. Which should the instructor explain for the acronym SOAPIER?

Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision

The nurse caring for residents of a skilled nursing facility wants to quickly check on the latest orders and medications for one client. Where should the nurse locate this information?

The Kardex

A client received a dose of intravenous pain medication before change of shift. After receiving the report, the oncoming nurse notes that the medication was not documented, provides another dose, and the client has a respiratory arrest. Who is most liable for this situation?

The nurse who gave the first dose of medication

While documenting in a client's chart, the nurse realizes that it is the wrong chart. What should the nurse do?

Write "mistaken entry" and place initials just above incorrect entry.