Chapter 16: Documentation

A community health nurse provides information to a patient with newly diagnosed multiple sclerosis for a support group at the local hospital for patients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following? a) A referral. b) Reporting c) Conferring d) A consultation

a) A referral.

A nurse is preparing a seminar on the uses of documentation in client records. Which topics should the nurse include in the seminar? (Select all that apply.) a) Decision Analysis b) Predictive outcome documentation c) Financial reimbursement d) Quality improvement e) Market Cost Analysis f) Research

a) Decision Analysis c) Financial reimbursement d) Quality improvement f) Research

How can a nurse obtain additional information about a client? a) Call the client's family. b) Read the client's history and assessment. c) Review nursing literature. d) Ask the client's sister about the family history.

b) Read the client's history and assessment.

A nurse is requesting to receive 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? a) "It will let me see everything that has been done and things that need to be done." b) "It will give me a better sense of what my workload will be today." c) "It will allow for us to see the client and possibly increase client participation in care." d) "It makes our client feel like we care, especially if we start the day off with a clean room."

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

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? a) Take the parent to the client's room and have the client give the requested information. b) Explain the reasons for the hospitalization, but give no further information. c) Provide the information to the parent. d) Ask the client if information can be given to the parent.

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

The nurse is preparing to call a physician to report a significant decrease in a client's oxygen saturation level. What action should the nurse do first? a) Request another nurse stay with the client while the report is called. b) Report the change to the physician using ISBAR. c) Document all findings in the electronic health record. d) Obtain all needed information to give report.

d) Obtain all needed information to give report. * The nurse should obtain all needed information first before calling the physician, and use the ISBAR format. The nurse will need to document all the findings in the client's record, but should contact the physician before documenting due to the significant change in oxygen levels. Asking another nurse to stay with the client is appropriate, but only after all information is gathered.

A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines? a) Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth b) Yelling at staff members, dementia worse today, refused breakfast c) Inappropriate behavior during breakfast, screamed during the shower, smiled while kicking other clients d) Confused, belligerent, and uncooperative with care

a) Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth *Nursing documentation should focus on behaviors and avoid words such as better, normal, or worse. Using the terms inappropriate behavior or belligerent are judgmental statements. The actual behaviors witnessed should be documented.

A nursing supervisor overhears one of the staff nurses say, "I only document vital signs when they are out of the normal range." What action by the nursing supervisor should be implemented first? a) Discuss with the staff nurse that the recording of all client data, even when normal, is important in providing and evaluating care. b) Review the staff nurses' documentation on assigned clients. c) Obtain copies of the hospital's policy on documentation and post it on the unit. d) Develop an inservice, highlighting the legal aspects of documentation along with hospital and accreditation requirements.

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

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation? a) It provides quick access to abnormal findings. b) It records progress under problems, intervention, and evaluation. c) It provides and refers to client's problem by a number. d) It documents assessments on separate forms.

a) It provides quick access to abnormal findings. *Charting by exception provides quick access to abnormal findings as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses

The nursing is caring for a client who requests to see a copy of his or her medical records. What action by the nurse is most appropriate? a) Review the hospital's process for allowing clients to view their medical records. b) Access the medical record at the bedside and show the client how to navigate the electronic medical record. c) Discuss how the hospital can be fined for allowing clients to view their medical records. d) Explain that only a paper copy of the medical record can be viewed by the client.

a) Review the hospital's process for allowing clients to view their medical records. *The nurse needs to be aware of the policies regarding clients reviewing medical records. Teaching the client how to navigate the medical records is not appropriate. Hospitals can be fined for not allowing clients to view their medical records. There is no regulation requiring the clients to view a paper copy of the records.

A student nurse asks a nurse why nurses cannot document in a separate record instead of the client record in order to document and find the information needed. What is the best response by the nurse? a) "The electronic medical record we use does not allow us to use different formats." b) "The Joint Commission requires nursing care to be permanently integrated into the client record." c) "The facility requires us to document client care this way because of the software used." d) "It would be easier to do it that way. You could develop a tool to use."

b) "The Joint Commission requires nursing care to be permanently integrated into the client record."

Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? a) A patient has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. b) A patient has asked a nurse if he can read the documentation that his physician wrote in his chart. c) A patient wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. d) A patient who resides in Indiana has required hospitalization during a vacation in Hawaii.

b) A patient has asked a nurse if he can read the documentation that his physician wrote in his chart. *Among the provisions of HIPAA are patients' rights to see and read their medical records. Negotiation with an insurance provider, the necessity of a second opinion, and out-of-state care are aspects of care that fall within the specific auspices of HIPAA.

A nursing student is preparing a presentation on client records and documentation. What information should the student include in the presentation? a) Clients should keep the original record at home in a fire proof safe. b) Communication is the primary purpose of client records. c) Nurses should not document progress notes in a client's record. d) Physicians will not review nurse?s documentation in the client's record.

b) Communication is the primary purpose of client records

A nurse on a night shift entered an elderly patient's room during a scheduled check and discovered the patient down on the floor beside her bed after falling when trying to ambulate to the washroom. After assessing the patient and assisting her back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? a) Protecting the nurse and the hospital from litigation b) Identifying risks and ensuring future safety for patients c) Following up the incident with other members of the care team d) Gauging the nurse's professional performance over time

b) Identifying risks and ensuring future safety for patients * Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team.

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? a) PIE charting b) SOAP charting c) Focus charting d) Narrative charting

b) SOAP charting * In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. Narrative charting is time-consuming to write and read, as it involves sorting through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

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? a) 930 pm b) 0930 c) 2130 d) 1930

c) 2130

A nurse is arranging for home care for patients and reviews the Medicare reimbursement requirements. Which patient meets one of these requirements? a) A patient who is not making progress in expected outcomes of care b) A patient whose status is stabilized c) A patient who is homebound and needs skilled nursing care d) A patient whose rehabilitation potential is not good

c) A patient who is homebound and needs skilled nursing care *Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.

Which of the following flow sheets provides the health care provider with information on an ongoing record of fluid loss? a) Critical care flow sheet b) Health assessment flow sheet c) Intake and output graphic sheet d) Vital signs graohic sheet

c) Intake and output graphic sheet

Which principle should guide the nurse's documentation of entries on the client's medical record? a) Nurses should not refer to the names of physicians. b) Correcting fluid is used rather than erasing errors. c) Documentation does not include photographs. d) Precise measurements are preferred over approximations.

d) Precise measurements are preferred over approximations.

When the nurse recognizes that he has documented one client's assessment data on the wrong client's medical record, the nurse should a) use a dark-colored felt-tip pen to black out the error. b) use correction fluid to cover the error and write the correct entry over it. c) replace the record sheet and write the correct entry on the new sheet. d) draw a single line through the error, initial it, and write the correct entry

d) draw a single line through the error, initial it, and write the correct entry