Chapter 16: Documentation and Communication in the Healthcare Team

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; respiration 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 of the following would the nurse document as "S"?

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

After educating a group of nursing students about the medical record and its purposes, the instructor determines that the group needs additional instruction when the students state which of the following?

"Medical records are primarily used for communication among nurses and physicians."

Which of the following statements indicates a correct way of conducting a change of shift handoff?

"The client is awake and alert and denied any chest pain in the entire shift."

Care plan conferences are done a weekly basis on the medical floor. The nurse is tasked to organize these meetings with other health care team members. What are the purposes of this meeting. Select all that apply.

- Rehabilitation plan from the physical therapist - Review of client's current progress - Discussion of the diabetic client's meal plan - Addressing the need for hospital bed when the client goes home

The nurse is in the process of reporting to the primary care physicians the changes in the client's status. Which interventions are done correctly? Select all that apply.

- Showing the physician the changes in the blood pressure reading - "Hello, Dr. Russ. The client's heart rate is 60 beats per minute. - Faxing the blood results to the physician's office

A nurse is working as part of a team that is presenting an in-service to the staff on the TeamSTEPPS program. Which skills would the nurse expect to be addressed as part of this program? Select all that apply.

- Team leadership - Communication - Situational monitoring - Mutual support

The nurse is calculating the intake of the client's lunch tray. The client drank 4 ounces of juice, 6 ounces of water and 8 ounces of coffee. The correct entry on the intake and output record is:

540 mL

Meaningful use of technology in client care and management is a goal for everyone involved. The transition from paper to electronic charting generates mixed responses from nurses. Which agency is responsible for monitoring compliance to Health Information Technology for Economic and Clinical Health (HITECH)?

Center for Medicare and Medicaid Services

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest?

Charting by exception

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal handoff report?

Current client assessment

During rounds, the nurse finds that a client with paralysis has fallen from the bed because the nursing assistant failed to raise the side rails after giving the client a bath. The nurse assists the client back to bed and performs an assessment of the client for injury. As per the agency policies, the nurse fills out an incident report. Which of the following would be most appropriate for the nurse to do?

Include time and date of the incident on the form.

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

Intervention carried PIE Notes: Nurse documents problem, intervention, and evaluation.

A nurse is preparing to document information about a client using the FOCUS system. Which information would the nurse record in the action section?

Interventions

A nurse is making a home visit to a client for the first time. The nurse is documenting assessment information on a laptop computer as each aspect of the assessment is completed. The nurse is using which of the following?

Point-of-care documentation

A newly hired nurse is participating in the orientation program for the healthcare facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as information to be recorded on the first step?

Problem selected

A nurse is caring for a client with bronchitis and phones the laboratory for the results of the client's sputum culture. Which of the following would be least appropriate to include when communicating with the laboratory?

Time the specimen was ordered.

A nurse is preparing to document care provided to a client. Which of the following would be most appropriate for the nurse to do to ensure that the documentation is concise?

Use phrases in narratives.

The nurse notes that the blood glucose level of a client has increased and is planning to notify the healthcare provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the healthcare provider?

SBAR

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which of the following would be most appropriate for the nurse to do?

Strike out with a single line and place initials.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which people would be entitled to access of the client's records?

Those directly involved in the client's care