PrepU ch. 16: Documenting, Reporting, Conferring, and Using Informatics

A nursing instructor is discussing a nursing student's social media post about an interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is most appropriate?

"Any information that can identify a person is considered a breach of client privacy."

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

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."

The nurse in making an entry on the client's charted "Medicated with meperidine 50 mg at midnight." How would the nurse document the entry using military time?

0000

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

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. What action by the nurse is most appropriate?

Ask the client if information can be given to the parent.

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

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

Which statement is not true regarding a medication administration record (MAR)?

If the client refuses the dose you don't have to document this on the MAR.

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.

How can the nurse researcher obtain information from a client record?

Study client records.

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.

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

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

urine output 100 ml

The nurse hears an unlicensed assitive personel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

Remind the UAP about the client's right to privacy.

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.

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and:

reimbursement

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."

What ensures continuity of care?

Communication

Which is not a purpose of the patient care record?

Contract

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 nurse is requesting to receive the change of shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving report at the bedside. Which response by the nurse receiving report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care."

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.

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.

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in charting?

"If I make an error, I draw a single line through it and put my initials by it."

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate learning was effective? Select all that apply.

"I will write, print, or type information legibly." "I will use only agency-approved abbreviations." "I will draw a straight line through any blank space."

The nurse is documenting an assessment that was completed at 9:30 pm. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

2130

The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr, The client is NPO and has received Morphine sulfate 4 mg IV for pain with a decrease of epigastrc pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method?

4/10 pain on pain scale, epigastric pain; with reports of nausea

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 in to 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.

What is the primary purpose of the client record?

Communication

The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? Select all that apply.

Documentation must be kept of personnel who have accessed a client's record. Light boxes for examining X-rays with the client's name must be in private areas. Conversations about clients must take place in private places where they cannot be overheard.

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.

A nurse documents the following client data in the patient 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

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?

Progress notes

The nursing is caring for a client who requests to see a copy of his or her health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records.

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

SOAP charting

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.

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.

To which Health Insurance Portability and Accountability Act regulation should the nurse adhere when safeguarding clients' written, spoken, and electronic information?

submitting a written notice to all clients identifying the uses and disclosures of their health information

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows what is important when working with a client translator?

Translators may need additional explanations of medical terms

A nurse is preparing an educational session on the purpose of documentation in health care records. Which topics should the nurse include in the education session? Select all that apply.

Facilitates quality Serves as a financial record Supports decision analysis Assists with clinical research

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

Which characteristic of a nurse's charting will assist most in the avoidance of errors?

Timeliness

Which documentation by the nurse best supports the PIE charting system?

Vomiting 250 mL undigested food, antiemetic given, no further vomiting