(PrepU) Documentation: Concept Exemplar

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. The statement uses approved abbreviations for complains of (c/o) and headache (H/A). Therefore the statement indicates that the client is complaining of a severe headache this morning. The abbreviation c/o stands for complains of, not coughing. The abbreviation H/A stands for headache, not heart attack or heartburn.

An older adult client has been admitted to the hospital with a suspected bowel obstruction. The nurse is reviewing the admitting healthcare provider's prescription, which reads "dimenhydrinate 25 mg intravenously q.i.d.; keep NPO." Based on this prescription, what action would the nurse take?

Ensure that the client does not eat or drink anything. The abbreviation "NPO" denotes that the client should take nothing by mouth. The abbreviation for "as needed" is "PRN." The prescription indicates to administer the medication four times a day, not twice a day. The prescription does not indicate the need for a nasogastric or oropharyngeal tube.

Which medication prescription by the health care provider will require the nurse to seek clarification?

Heparin 5,000 u SC every day The abbreviation "u" should not be used alone because it can be mistaken for a zero, a 4 or "cc". The word "unit" should be written out to avoid confusion. All of the other prescriptions are written correctly.

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 An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions Omitting clients' responses to nursing interventions is correct because it does not fit the criteria for legally defensible charting. Recording nursing interventions, identifying nursing diagnoses or client needs, and documenting clients' health histories and discharge planning are all criteria for legally defensible charting and would demonstrate evidence of quality care.

Which abbreviation is correct for use in documentation?

PO Facilities develop acceptable abbreviation lists based on guidelines from oversight agencies. PO, which is a derivative abbreviation from the Latin term "per os," signifying "orally" or "by mouth," is a commonly approved abbreviation. "Sub q" (meaning "subcutaneous"; SC is preferred), "Per os" (meaning "orally" or "by mouth"; PO is preferred), and "BT" (meaning "bedtime"; can be confused with "BID," meaning "twice daily") are not generally accepted abbreviations.

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. Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers is an advantage of problem-oriented recording and is therefore correct. Giving clients the right to withhold the release of their information to anyone is a beneficial disclosure and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving clients' problems among caregivers and having numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care are examples of source-oriented recording.

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

a flow sheet A flow sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special needs.

The nurse is documenting client information in the client's medical record. Which action by the nurse is appropriate when documenting information in a client's medical record?

ending each entry with a signature and title The end of each entry should include the nurse's signature and title; the signature holds the nurse accountable for the recorded information. The nurse can refer to the client and care providers by name in the medical record because it is kept secure and contains numerous identifiers already. Practitioners being referred to in a note should be identified by name instead of by titles (e.g., physician or charge nurse). The nurse is accountable for the information recorded and therefore shouldn't leave any blank lines in which another healthcare worker could make additions.

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 In addition to avoiding abbreviations prohibited by the Joint Commission, it is important to limit the use of abbreviations to those recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.