Chapter 16: Documenting
Which principle should guide the nurse's documentation of entries on the client's medical record?
Precise measurements should be used rather than approximations. Correct Explanation: Precise measurements and times must be used whenever possible. It is appropriate to use the names of physicians, and photographs can constitute documentation. Handwritten entries should be struck through with a single line, not covered with correcting fluid or erased. (less)
A client is scheduled for a CABG procedure. What information should the nurse provide to the client?
"A coronary artery bypass graft will benefit your heart." Correct Explanation: Coronary artery bypass graft is abbreviated CABG. It does not idetify nutritional needs, decrease liver inflammation, or increase intestinal motility.
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?
"It will allow for us to see the client and possibly increase client participation in care." Explanation: Beside reports are driven to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused. (less)
The nurse manager overhears a nurse say, "I'm not going to fill out an incident report because it will be used against me." What response by the nurse manager is most appropriate?
"The main purpose of an incident report is for quality improvement, not disciplinary action." Incident reports should not be used punitively. They should be used to improve safety and client outcomes. The number of reports submitted by a nurse is irrelevant for punitive action because the report may be submitted for a systems error, not a nursing error. Even minor occurrences need to be addressed. It is unrealistic to assume every nurse will not make a single mistake or that a systems error can be avoided. (less)
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 Correct Explanation: The nurse should write "1 Unit of glucose." The nurse cannot write "1 bottle" or "one U of glucose" because these are not the accepted standards. "1U" is an abbreviation that appears in the JCAHO "Do Not Use" list (see http://www.jcaho.com). It should be written as "1 Unit," instead of "1U" because "U" is sometimes misinterpreted as "zero" or "number 4" or "cc." (less)
Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?
A client has asked a nurse if he can read the documentation that his physician wrote in his chart. Correct Explanation: Among the provisions of HIPAA are clients' 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. (less)
Which documentation tool will the nurse use to record the client's vital signs every 4 hours?
A flow sheet Correct Explanation: 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. (less)
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. Correct Explanation: No information should be provided by the nurse without permission from the client. Taking the parents to the client's room to get information from the client may violate the client's privacy. (less)
What is the primary purpose of the client record?
Communication Correct Explanation: The primary purpose of the client record is to help health care professionals from different disciplines communicate with one another.
According to the American Nurses Association (ANA), what is the primary source of evidence to measure performance outcomes against standards of care?
Documentation Correct Explanation: Documentation is the primary source of evidence use to measure performance outcomes, according to the ANA. Accreditation, psychomotor skills, and clinical judgment are incorrect.
A nurse is preparing an educational session on the purpose of documentation in medical 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 Explanation: Documentation provides data to facilitate quality, serve as a financial record, assist with clinical research, and support decision analysis. Documentation does not serve to provide personal communication to the family. (less)
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. Correct Explanation: If a client refuses a dose, it is important to circle that dose and write a note as to why you did not administer it.
The nurse is documenting a variance that has occurred during the shift, and 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 Correct Explanation: 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. (less)
A physician is in a hurry to leave the unit and tells the nurse to give a morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?
Inform the physician that a written order is needed. Explanation: Verbal orders should only be accepted during an emergency. No other action is correct other than asking the physician to write the order.
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. Correct Explanation: Charting by exception (CBE) 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. (less)
A nurse documents the following patient data in the patient record according to the SOAP format: Patient complains of unrelieved pain; patient is seen clutching his side and grimacing; patient 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 Correct Explanation: The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of patient problems and contributes collaboratively to the plan of care. Progress notes clearly focus on client problems. Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically. PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). Focus charting method brings the focus of care back to the client and the client's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a client and client care. (less)
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 Correct Explanation: In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem. (less)
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.
Quality improvement • Research • Decision Analysis • Financial reimbursement Explanation: Quality improvement, research, decision analysis, and financial reimbursement are all uses for documentation. Market cost analysis and predictive outcome documentation are not uses for documentation. (less)
The nurse receives a verbal order from a physician during an emergency situation. What actions should be taken by the nurse? (Select all that apply.)
Read back the order. • Mark the date and time of the order. • Include V.O. with the physician name on the order. Explanation: When a verbal order is received during an emergency, the nurse should record the order in the medical record, read back the order, mark the date and time of the order, and record V.O. with the name of the physician who issued the order. After the emergency situation, the physician should review and sign the order. (less)
In order 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 Correct Explanation: SBAR stands for Situation, Background, Assessment, and Recommendations.
The nurse hears a nursing assistant discussing a client's allergic reaction to a medication with another nursing assistant in the cafeteria. What is the highest priority nursing action?
Remind the nursing assistant about the client's right to privacy. Explanation: The nurse should first remind the nursing assistant about the client's right to privacy. All other actions are appropriate, but do not immediate protect the client's privacy.
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?
Review the hospital's process for allowing clients to view their medical records. Explanation: 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. (less)
Charting in which the nurse writes a progress note that relates to one health problem is a:
SOAP note Correct Explanation: SOAP note is a progress note that relates to only one health problem. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 353.
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. Correct Explanation: Subjective data should be included when using the SOAP format for documentation. Objective data is what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care providers' judgment of the situation, and abnormal lab values would be included in objective data. (less)
A client has requested a translator so that she can understand the questions that the nurse is asking her during the client interview. The nurse knows what is important when working with a client translator?
That translators may need additional explanations of medical terms Correct Explanation: When using a translator it is important to remember that the client still comes first. This means that all information is directed at them and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member such as when you are talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across hostile and rude. It is true that even professional translators don't understand all medical terms and may need some clarification at times. (less)
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. Explanation: A nursing care conference is a meeting of nurses to discuss some aspect of a client's care. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 16: Documenting, Reporting, Conferring, and Using Informatics, p. 363. Chapter 16: Documenting, Reporting, Conferring, and Using Informatics - Page 363
A new graduate is working at her first job. Which statement is most important for the new nurse to follow?
Use abbreviations approved by the facility. Correct Explanation: Use abbreviations, but only those that are commonly accepted and approved by the facility. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 345. Chapter 16: Documenting, Reporting, Conferring, and Using Informatics - Page 345
A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease, and their families. Providing this information is an example of:
a referral. Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others. (less)
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 her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into 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 Correct Explanation: 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. (less)
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:
interpretation of data. Correct Explanation: It is always best to describe behavior rather than to interpret behavior. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client. Stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. (less)
Besides being an instrument of continuous client care, the client's medical record also serves as a(an):
legal document. Correct Explanation: The client record serves as a legal document of the client's health status and care received.
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. Correct Explanation: In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are 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. (less)
When taking a telephone order from a physician, the nurse verifies that she understands the order by:
repeating the order back to the physician. Correct Explanation: The nurse should repeat every telephone order back to the physician to ensure that she correctly understands what was ordered. If the nurse is unsure of the order given by phone, she asks the physician to repeat it; this is not a summary of the order. Confirming the order with the nurse manager is not an effective means to verify the order, because the nurse manager will likely not be available during the telephone conversation. (less)
