Unit 2-CH 10 Documentation

A Charge Nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select All that Apply) A) Cover Errors with correction fluid, and write in the correct information B) Put the date and time on all entries C) Document Objective Data, leaving out opinions D) Use as many abbreviations as possible E) Wait until the end of the shift to document

B,C

Which attributes are important in nursing documentation? (Select all that apply.) a. Inconsequentiality b. Timeliness c. Relevancy d. Accuracy e. Factual basis

B,D,E,C

Which statement best contributes to the nurse's documentation of assessment of patient status in the patient's medical chart?

C) "Patient rated pain 7/10 at 7:45 a.m. Received pain medication at 8 a.m., reporting pain 3/10 at 8:30 a.m."

What is an advantage of the use of electronic medical records?

A) Electronic health records (EHRs) are always available to all health care team members.

What is a purpose of a hand-off report?

A) Ensures continuity of care and patient safety

Which note is an example of the S in SBAR?

A) Patient resting; pain was rated 3/10 1 hour after receiving narcotic analgesic.

A patient requests a copy of his medical record. What is the correct response by the nurse?

C) Acknowledge that he has the right to have a copy of his records, and make arrangements per facility policy.

The nurse has made an error in a narrative documentation of an assessment finding on a client andobtains the client's record to correct the error. The nurse should take what actions to correct theerror? Select all that apply.a. Document a late entry in the client's record.b. Draw 1 line through the error, initialing and dating it.c. Try to erase the error for space to write in the correct data.d. Use white out to delete the error to write in the correct data.e. Write a concise statement to explain why the correct was needed.f. Document the correct information and end with the nurse's signature and title

A, F

1. Which are reasons that accurate documentation in the medical record is important? (Select all that apply.) a. Reimbursement for care b. Evidence of care provided c. Communication between health care providers d. Non-legal documentation of a nurse's actions e. Promotion of continuity of care

A,B,C,E

. Which identifies accurate nursing documentation notations? Select all that apply. a. The client slept through the night. b. Abdominal wound dressing is dry and intact without drainage. c. The client seemed angry when awakened for vital sign measurement. d. The client appears to become anxious when it is time for respiratory treatments. e. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

A,B,E

Where would you document vital signs and I&Os?

Flowsheet

When should administered medications be documented?

B) As given to avoid the possibility of double dosing

1. A hospital has implemented the use of electronic health records (EHRs). While learning to use this system, the nurse realizes that EHRs may do which of the following?

B) Improve access to the patient record to one person at a time

The physician orders: MSO4 2mg IV prn pain q 4-6 hours. Is this a good order?

B) NO

A patient's sister comes to visit and asks to read the patient's medical records. What is the best response by the nurse?

B) Respond that the contents of a patient's medical records are private and confidential.

How would you document if the patient ate half of the pastry and the whole cup of coffee?

Patient ate 50% and 250 mL of coffee for breakfast

The nurse is reviewing and order the physician has written using the abbreviation qid. Which of the following is the correct interpretation for this abbreviation?

c. Four times a day

The nurse is checking the vital signs of the patient that she has just received report on. Where would the nurse look to find this information?

c. Graphic record flow sheet