Fundamentals- Ch.19
In SBAR, what does R stand for?
Recommendations Explanations: SBAR stands for situation, background, assessment, and recommendations. The other responses are incorrect.
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 a neighboring state. p.455
A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy?
Use minimum disclosure policy to release the information. Explanation: The nurse should use minimum disclosure policy to release the information, as per HIPAA regulations. It is inappropriate to not release any information to the insurance company, to refer the insurance agent directly to the client, and to release the full medical record to expedite payment. p.457
Which statement regarding FOCUS charting is most accurate?
The charting focuses on client strengths, problems, or needs. p.469
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."
The nurse is using the ISBARR format to report a surgical client's deteriorating condition to a health care provider. Which actions would the nurse perform when using this guide? Select all that apply.
-After introductions, the nurse states the client name, room number, and problem. -The nurse states that the client's condition "could be life-threatening." -The nurse reads back the physician's new orders at the conclusion of the call.
Which is the primary purpose of client records?
Communication
Which documentation by the nurse best supports the PIE charting system?
Vomiting 250 mL undigested food, antiemetic given, no further vomiting Explanation: PIE charting includes the problem, intervention, and evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (problem), antiemetic given (intervention), no further vomiting (evaluation). p. 469
What ensures continuity of care?
communication Explanation: Communication ensures continuity of care and provides essential data for revision of. or continuation of care. The acts of reassessment, critical thinking, and integration do not contribute directly to contiinuity of care. p.463
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:
interpretation of data. p.456
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?
"Legal policy requires nursing practice to be permanently integrated into the client record." p.453
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 p.478
A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment?
The lower extremities Explanation: Peripheral vascular disease mostly affects the lower extremities. While the lung sounds, heart rate and rhythm, and abdominal assessment will be important, the focused assessment should be on the lower extremities. p.459
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. Explanation: A nursing care conference is a meeting of nurses to discuss some aspect of a client's care. p.479
Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records?
"The clients' medical records are an obstruction to research and education." Explanation: The clients' medical records are good sources of data for research and education, and, therefore, it is incorrect to say that they are an obstruction. The other statements do not need correction. p.464-465
The nurse receives a verbal order from a physician during an emergency situation. Which actions should be taken by the nurse? Select all that apply.
-Read back the order. -Mark the date and time of the order. -Include V.O. with the physician name on the order. Explanation: When a verbal order is received during an emergency, the nurse should record the order in the medical record, read back the order, mark the date and time of the order, and record V.O. with the name of the physician who issued the order. After the emergency situation, the physician should review and sign the order. Pharmacy discrepancy sheets are used to record discrepancies in medication inventories, which could indicate diversion, or theft, of prescription medications. p.464
Which actions should the nurse take before making an entry in a client's record? Select all that apply.
-Reviewing the agency's list of approved abbreviations -Locating clients' files within an electronic health record system -Identifying the form appropriate to be used for documenting Explanation: The nurse should review the agency's list of approved abbreviations, as each agency may use a different set of approved abbreviations and has approved its use for legally defensible reasons. The nurse should locate clients' files within an electronic health record system rather than creating a new record, to avoid duplication and missing important information in the client's record that was added previously. The nurse should identify the form appropriate to use for documenting, becaise some aspects of clients' care are recorded on specific forms. The nurse should use the charting format required by the facility, not choose one that the nurse prefers. The client's name should be identified on chart forms, so that if the forms become separated from the chart, the nurse will still be able to identify which client chart they belong to. p.455
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-oriented method Explanation: 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. Progress notes clearly focus on client problems. Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically. PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). Focus charting method brings the focus of care back to the client and the client's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a client and client care. p.468
The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?
Reporting
A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation?
Source-oriented Explanation: A source-oriented record is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically, with the most recent entry being nearest the front of the record. Problem-oriented medical record (POMR) or problem-oriented record is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. PIE charting system is unique in that it does not develop a separate care plan. The care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified). In this documentation system, a client assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms (flow sheets). Client problems identified in these assessments are numbered, documented in the progress notes, worked up using the problem, intervention, evaluation (PIE) format, and evaluated each shift. Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes. p.467
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 nurse is documenting care for a client with diabetes. Which nursing documentation will The Joint Commission review? Select all that apply.
-nursing care provided -physical assessment -nursing diagnoses -client teaching Explanation: The Joint Commission reviews nursing documentation containing assessment and reassessment, nursing diagnoses, client needs, nursing interventions, education, fall strategies, and nursing care. Another member of the healthcare team will secure method of payment. p.453
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 p.456
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. p.457
A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?
Calling the client information desk to find out the room number of the family member p.455
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. p.455
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. p.469
What dual purpose does an audit serve?
quality assurance and reimbursement Explanation: Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits have no role in communications, evaluation, knowledge, quality, education, or confidentiality, p.463
Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.
-Obscuring identifiable names of clients and private information about clients on clipboards -Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public -Keeping record of people who have access to clients' records
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."
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 p.456
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."
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?"
A nurse helps a client who has cystic fibrosis prepare a stand-alone personal health record. Which statement by the nurse best explains this type of information?
"You can fill in information from your own records and store it on your computer or the Internet."
A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as?
A variance Explanation: This scenario reflects a variance in care. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client. p.470
A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?
Accurately documenting client care on the client record Explanation: The client record is the only permanent legal document that details the nurse's interactions with the client and is the nurse's best defense if a client or client surrogate alleges nursing negligence. As the question is written, the only answer that addresses the situation is accurate documentation of the event in the client's record. Notifying the nursing team of the client's condition is important, but not the correct answer for the question. Client data should be correctly documented on the flow sheet, but this is not the correct answer in this case. The medication record should be accurate, but this is not the best answer. p.453
A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation?
Attach a copy of the incident report to the chart.
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. p.456
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. p.468
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. Explanation: When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times. p.479
Which documentation tool will the nurse use to record the client's vital signs every 4 hours?
a flow sheet
The client record is utilized for many purposes. Which might be uses for the client record? Select all that apply.
education of student nurses reimbursement for services research education for medical students p.463-465
The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?
subjectivity Explanation: Quoting what the client is saying helps in the documentation of subjective data. Objective data are assessment data that may be directly observed by the nurse such as blood pressure. Organization is the structure of the documentation and does not relate to subjective data. Reimbursement is a distractor that doesn't relate to assessment data. p.469
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 p.455
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." Explanation: 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. The other answers are therefore inappropriate responses. p.466
The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate?
"The benefit of CBE is less time needed on computer charting." Explanation: One of the benefits of CBE is less time needed for documentation. CBE does not always support high-quality care and is not the best way to protect against lawsuits since not all data are documented. CBE is not a new format for documentation. p469
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.
A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as?
A variance Explanation: This scenario reflects a variance in care. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client. This scenario reflects a variance in care. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client. p.470
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 Explanation: An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences. p.478
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. Explanation: If the nurse is using an EMR and the documentation cannot be changed, an addendum will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies. The health care provider does not need to be contacted to make a correction, but does need to be informed if this caused any direct harm or effects to the client. p.456
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.
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.
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 p.453-454
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
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 Explanation: 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. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation. p.469
Which is not a purpose of the client care record?
To serve as a contract with the client Explanation: Client care records are legal documents, communication tools, and assessment tools. They are used for care planning, quality assurance, reimbursement, research, and education. They in no manner reflect a contract between health care staff and the client. The only exception to this is at the point of admission when the client (or responsible party) signs an acknowledgement of expenses about to be incurred as health care insurance information is obtained. p.464-465
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. Explanation: Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the physician section. Critical pathways are not used to document physical assessments. p.467
Which is the proper way to document midnight in a client's record?
0000 Explanation: 0000 is the military time for midnight and is correct. The other military times are incorrect since 2401 is 1 minute past midnight, 1200 is noon, and 1201 is 1 minute past noon. p.456
The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?
The client reports waking up this morning with a severe headache. p.459
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
A client's record can be more accurate if the nurse:
uses point-of-care documentation. Explanation: Point-of-care documentation takes place as care occurs, thus enhancing accuracy. Today many facilities incorporate technology that is mobile and can be used immediately at the client's bedside for point-of-care documentation. The nurse should not delegate documentation, nor should it be left to the end of a shift. Documentation should be performed more than once every 6 hours. p.465
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 p.478
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." Explanation: SBAR refers to: S (situation): what is the situation you are calling about?; B (background): pertinent background information related to the situation; A (assessment): what is your assessment of the situation?; R (recommendation): explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format. p.477
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. 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. Explanation: Examples of using the SBAR technique are numerous. The nurse handling the transfer describes the client situation to the new nurse. The nurse gives the background of the client by explaining the client history. The nurse presents an assessment of the client to the new nurse. The nurse gives recommendations for future care to the new nurse in charge. The nurse does not explain the rules of the new facility to the client as part of the SBAR technique. The nurse would discuss the client's symptoms with the new nurse in charge as part of the "B" background, not the "S" situation. p.477
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.
A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them.
-"I don't feel well. I've been urinating often, and it burns when I urinate." -Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. -Fever, possible urinary tract infection -Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. Explanation: When using the SOAP format, the nurse would first document the subjective data (S: the client's complaint), objective data (O: abdomen, urine characteristics, temperature and contributing factors), assessment (A: caregiver's judgment about the situation—fever and possible urinary tract infection), and plan (P: what the caregiver is going to do—notify the physician, encourage fluids, and continue to monitor).
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 Explanation: Any identifying information regarding the client's demographics such as name, age, gender, diagnosis, and so on should be communicated to the oncoming nurse caring for the client. Any current orders or orders that have not been completed during the shift should be communicated as well. The oncoming nurse should be informed of any occurrences with the client that have been out of the norm and what actions, if any, were taken. Information about what the client watched for entertainment is not of relevance and should be eliminated from the report, as well as what time the nurse will be working next.
Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?
Submitting a written notice to all clients identifying the uses and disclosures of their health information Explanation: Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the physician's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations. p.457
The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider?
The nurse can accept verbal orders to provide immediate care and record once the client is stable.
A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest?
charting by exception Explanation: The team would most likely suggest the use of charting by exception, which is an abbreviated form of documentation. Narrative notes are time-consuming to write and require much reading to learn about a specific problem. The problem, intervention, and evaluation note system simplifies documentation by incorporating the plan of care into the progress notes. The FOCUS system of documentation organizes entries by data, action, and response. This system is broader in its view because a FOCUS can reflect a possible problem area but does not need to be an actual problem. p.469
A client reports to the nurse quitting smoking 6 months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome?
reimbursement. Explanation: Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits do not play a role in staff development, research, or change of mechanisms within a system.
A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication?
"I think the client would benefit from intravenous furosemide." Explanation: Situation, background, assessment, and recommendations (SBAR) provides a consistent method for hand-off communication that is clear, structured, and easy to use. The S (situation) and B (background) provide objective data, whereas the A (assessment) and R (recommendations) allow for presentation of subjective information. Calling to report dyspnea and crackles occurs as the nurse describes the situation. Providing the medical history occurs as the nurse offers important background information. Stating that the client has fluid volume overload is the assessment of the nurse. Stating that the nurse thinks the client would benefit from intravenous furosemide is the nurse's recommendation. p.474
