PREP U CH.16 Documentation & Communication

Which data entry follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting."

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

A flow sheet

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

What is the primary purpose of FOCUS charting?

Client concerns

A nursing supervisor overhears one of the staff nurses say, "I only document vital signs when they are out of the normal range." Which action by the nursing supervisor should be implemented first?

Discuss with the staff nurse that the recording of all client data, even when normal, is important in providing and evaluating care.

Which part of the client's record is commonly used to document specific client variables, such as vital signs?

Flow Sheets

A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis?

Public Health Department

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?

Subjective data should be included when documenting

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."

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

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document?

Intervention carried out

To improve communication within the health care system, tools were created to standardize the process and assist with clarity and conciseness. SBAR is one such tool. In this tool, what does R stand for?

Recommendations

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 diseases and their families. Providing this information is an example of:

Referral

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.

What is the primary purpose of the client record?

Communication

The following information appears on a client's medical record: Client states, "I have a fair amount of pain in my belly near my incision"; heart rate 88; respirations 22; abdomen distended; incision clean and dry; last medicated for pain 5 hours ago; abdominal pain secondary to surgery 2 days ago; reassess pain level using pain rating scale in 30 minutes; administer oxycodone 5 mg as ordered; monitor vital signs every 4 hours; client lying on side with legs drawn up and massaging abdominal area. When documenting this information using the SOAP method, which part would the nurse document as "S"?

I have a fair amount of pain in my belly near my incision"

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 patient records but cannot view the details.