Fundamentals Test 2 (documentation)

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."

What are the Purposes of Records?

-COMMUNICATION BETWEEN DISCIPLINES -Legal documentation -Financial -Education -Research -Auditing/monitoring

Examples of Confidential Information--

-Discussing patient in public area -Leaving patient information in a public area -Leaving computer unattended -Failing to log off a computer -Copying or providing data to others except as needed to fulfill job -Improperly accessing, reviewing or releasing patient information

Charting Errors/Red Flags-

-Erasures or obliterations -An entry written over a previous entry to correct or change it -Pages without any patient identification -Changes in slant, uniformity, or pressure of handwriting or changes in ink or pen on the same entry -Lack of patient teaching or discharge instructions -Charting inconsistencies such as lapses in time -References to an incident report -Battles between health care providers -Fraudulent or improper alterations of the record -Destruction of records or missing records

The Nursing Process-

-Follow institutions policies for documentation -Perform and document a complete initial nursing assessment for each patient -Document all findings and interventions -Write the complete date, time, and sign your name and credentials -Continually reassess your patient's condition -Document all reassessment findings and interventions

Documentation Methods:

-Narrative -SOAP -PIE -Focus Charting

A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose

Parts of a Medical Record--

1. Admission sheet 2. Admission nursing assessment 3. Graphic sheet 4. Flow sheet 5. Narrative nursing notes 6. Medication sheet or MAR 7. Medical History - History and Physical 8. Physician order sheet 9. Physician progress notes

Breaches in Confidentially--

1. Computers 2. Copiers 3. Cell phone 4. Fax machine 5. Voice pagers

Legal Guidelines to Confidential Information-

1. Do not erase, whiteout, scratch out errors 2. Do not document critical comments 3. Correct all errors promptly 4. Record all facts 5. Do not leave blank spaces 6. Legible black ink 7.Record if clarification sought 8. Chart only for yourself 9. Keep password to yourself

The 8 Core Capabilities that EHR's should possess are--

1. Health Information and Data 2. Result Management 3. Order Management 4. Decision Support 5. Electronic Communication and Connectivity 6. Patient Support 7. Administrative Processes 8. Reporting

Which of the following clinical situations 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.

Follow the Nursing Process when documenting-

Assessment Plan/Goal Intervention Evaluation

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

________ is Charting by Exception and permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution

CBE

Administrative Processes-

Computerized administrative tools, such as scheduling systems, would greatly improve hospitals' and clinics' efficiency and provide more timely service to patients.

5 Guidelines of Documentation-

Content Timing Format Accountability Confidentiality

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal handoff report?

Current client assessment

Errors in documentations--

Draw a single line through the incorrect entry so that it remains legible. May include a note. Ex. Charted on wrong chart or mistaken entry. Never use correction fluid, erase or obliterate the first entry.

______ is Electronic Medication Administration Record, which documents medication administration.

EMAR

Electronic Communication and Connectivity-

Efficient, secure, and readily accessible communication among providers and patients would improve the continuity of care, increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events.

Reporting-

Electronic data storage that employs uniform data standards will enable health care organizations to respond more quickly to federal, state, and private reporting requirements, including those that support patient safety and disease surveillance."

Documentation Pitfalls Include:

Gaps Bias Deviation from policies and procedures

Health Information and Data--

Having immediate access to key information - such as patients' diagnoses, allergies, lab test results, and medications - would improve caregivers' ability to make sound clinical decisions in a timely manner.

________________ has extensive requirements for protection of the patient's health information, which they refer to it as PHI (protected health information)

Health Insurance Portability and Accountability Act (HIPAA)

______ has a list of approved abbreviations

Hospital

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 her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into 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

Legal Implications of Confidential Information-

If it is not documented it was not done Do not chart prior to event

During rounds, the nurse finds that a client with paralysis has fallen from the bed because the nursing assistant failed to raise the side rails after giving the client a bath. The nurse assists the client back to bed and performs an assessment of the client for injury. As per the agency policies, the nurse fills out an incident report. Which of the following would be most appropriate for the nurse to do?

Include time and date of the incident on the form

What organization audits charts regularly?

Joint Commission on Accreditation of Healthcare Organizations

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

Limiting abbreviations to those approved for use by the institution.

Confidential Information:

Methods of communicating Names and all identifiers Reason that the patient is seeking care Past Health Conditions

A health care agency has been asked to compensate a client as per a lawsuit filed against it for not following the Health Insurance Portability and Accountability Act (HIPAA) regulations. Which of the following situations is a HIPAA violation?

Not informing a client in writing of the purpose of sharing his or her personal details

In many institutions, which of the following telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner?

Orders for antibiotics

3 Methods of Communicating:

Paper Computer Spoken

Legal Standards of Confidential Information:

Patient records must be legible, express clarity, and accuracy. All entries must be in ink, black

Benefits of an Electronic Health Record (EHR)-

Physicians, nurses and other healthcare workers have immediate access (no searching for the patient record) No lost records

A nurse is caring for a client at the local health care facility. Which of the following should the nurse do to ensure that the HIPAA legislation is implemented at the facility?

Place light boxes for examining x-rays with the client's name in private areas.

PIE Documentation Method-

Plan Intervention Evaluation

How can a nurse obtain additional information about a client?

Read the client's history and assessment.

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic client chart is what?

Retrieval of information is more efficient.

SBAR:

S ituation B ackground A ssessment R ecommendation

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

SBAR

A health care facility plans to evaluate and revise the plan of care for a client based on the client's medical records. The physician, dietitian, and the nurse involved in the client's care are required to collate all of the information for easy access. Which style do you think the agency is following in order to record the client details?

SOAP Charting

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 nursing implementing?

SOAP charting

Abbreviations in Medical Documentation are used to:

Save time Reduce the size of the chart Standardized

SOAP Documentation Method-

Subjective Objective Assessment Plan

Result Management--

The ability for all providers participating in the care of a patient in multiple settings to quickly access new and past test results would increase patient safety and the effectiveness of care.

Order Management--

The ability to enter and store orders for prescriptions, tests, and other services in a computer-based system should enhance legibility, reduce duplication, and improve the speed with which orders are executed.

A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?

The laboratory assistant can only retrieve medical records but cannot view the details.

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.

A nurse uses the computer to access health records of the clients. What care should the nurse take when using a computer to access health records?

The password and access number should be kept secret and changed regularly.

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 refuses. The nurse's refusal is based on the understanding that which of the following people would be entitled to access of the client's records?

Those directly involved in the client's care

Patient Support-

Tools that give patients access to their health records, provide interactive patient education, and help them carry out home-monitoring and self-testing can improve control of chronic conditions, such as diabetes.

Flow Sheets-

Trends are easily seen Time decreased Must be complete

Examples of Prohibited Abbreviations--

U - mistaken for zero, four, or cc. Preferred term : unit. Q.D. and Q. O. D. - mistaken for each other. Preferred - daily or every other day Trailing zero - never write a 0 after a decimal point ex. 1.0 could be mistaken for 10. Always write a decimal point before the decimal point ex 0.2 MS - Write morphine sulfate or magnesium sulfate

Discharge Summary-

Use clear, concise descriptions in client's own language Review signs and symptoms of complications that should be reported to a physician Provide step-by-step description of how to perform a procedure (ex. Medication administration, dressing change)

Decision Support-

Using reminders, prompts, and alerts, computerized decision-support systems would help improve compliance with best clinical practices, ensure regular screenings and other preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments.

Timely Enteries include:

Vital signs Patient assessment Administration of medications and treatments Prep for surgery or diagnostic tests Change in patient status/your response/patient response Admission, transfer, discharge, death

Adding notes to document is required when-

When a procedure is performed When there is a change in the patient's status When communicating with the physician/NP Receiving a patient following a procedure or surgery Admissions, transfers, discharges

Which documentation tool will the nurse use to record the patient's vital signs every 4 hours?

a graphic sheet

When using a flow sheet, the ______ and _____ must be recorded in the notes

assessment & action

Use descriptive terms for documentation including-

body location body functions skin characteristics nutrition drainage or secretions

If an occurrence is unusual of a flow sheet or a change occurs, a _____ is needed.

focus note

Besides being an instrument of continuous client care, the client's medical record also serves as a(an)

legal document

Besides being an instrument of continuous client care, the client's medical record also serves as a(an) __________

legal document

Among the provisions of HIPAA are clients' rights to see and read their _______

medical records

When performing a discharge summary, the nurse should list---

names & numbers of health care providers and resources actual time of discharge mode of transportation who accompanied the patient

Document both the _____ and ______

patients statements and your observations Example: " I feel sad" or " I feel depressed" - does not smile, avoids eye contact, drooping posture, cries,

JCAHO has identified a list of abbreviations that must be-

prohibited as part of their national safety goals.

When taking a telephone order from a physician, the nurse verifies that he or she understands the order by ...

repeating the order back to physician

Because of HIPPA, access to patient record is--

restricted to those in the facility using it for care

Incident report should include--

time and date of the incident on the form the events leading up to it, the client's response, and a full nursing assessment. To prevent legal issues, the nurse should not attach the copy of the incident report to the client's records. Also to prevent litigation, the fact that the incident involved an error should not be highlighted in the client's records. Since the client report is a legal document, it should not contain the name of the nursing assistant

Narrative Documentation Method-

using sentences

The nurse should use SBAR to communicate ______ to the healthcare provider.

verbally