Chapter 16 Documenting, Reporting, Conferring

A concise document that provides most of the client's nursing and medical information is a(n):

Kardex. Explanation: The Kardex is a way to ensure continuity of care from one shift to another and from one day to the next.

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mm Hg when all other vital signs are normal. This reflects what type of documentation?

charting by exception Explanation: Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. In the scenario, the BP is abnormal and is documented by exception. The other types of documentation are not being represented in this scenario.

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?

Ensure that the client's name appears on all pages. Explanation: The nurse should ensure that the client's name appears on all pages to ensure legally defensible charting. The nurse should not leave spaces between entries and signature so that the document is legally acceptable. The nurse should use only abbreviations approved by the facility, and should not use abbreviations wherever possible. The nurse should record all the facts but not any subjective interpretations, to ensure that the document is legal evidence.

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 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.

How can a nurse obtain additional information about a client?

Read the client's history and assessment. Explanation: Nurses and other team members gather assessment data from the client record. By reading about the client's history and initial assessment, and comparing these data with additional subjective and objective information that has been obtained, current health status and progress toward goals can be determined.

Which information the nurse is expected to find on the nursing Kardex? Select all that apply.

the level of activity for the client the current medical order for the client the client's preparedness for an investigation Explanation: The client's level of activity, current medical order, and preparedness for an investigation are correct, as these are current information about the client's care and are expected to be seen on the nursing Kardex. The duty roster, meals, and breaks for staff will be recorded on the client care assignment.

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs oedmatous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now oedema +"?

focus charting Explanation: Focus charting is correct, as it gives priority attention to the client's current or changed behavior. Pie charting occurs when the nurse records the client's progress under the headings of problem, intervention, and evaluation. Narrative charting content resembles a log or journal entry. Charting by exception is charting only abnormal assessment findings that deviate from a standard norm. Therefore, this nurse is not demonstrating pie, narrative, or exception charting.

A nurse is taking care of a client post knee surgery. The nurse follows a clinical pathway that guides the care of this client after this specific procedure. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What does the nurse identify this even as?

variance. Explanation: A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed, documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb, or a serious injury to a client.

Which nurse to provider interaction correctly utilizes the SBAR format for improved communication?

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." Explanation: SBAR refers to: S (Situation): What is the situation you are calling about; B (Background): Pertinent background information related to the situation; A (Assessment): What is your assessment of the situation; R (Recommendation): Explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.

The parents of a hospitalized child ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?

"I will arrange access for you to review the record after you put your request in writing." Explanation: Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. It is the parents' right to view the client's record. Therefore, the statements about the physician not giving the parents access to review the records and asking if the parents have specific questions are incorrect. The client is a minor, so the legal guardian has the right to view the records

The unlicensed assistive personnel (UAP) has taken vital signs. The nurse is currently logged into the electronic health record, and the UAP needs to document the vital signs. How does the nurse answer the UAP's request to document?

"I will log out of the electronic health record and you can log in to document." Explanation: Each person who makes entries in the client's medical record is responsible for the information he or she records, and can be summoned as a witness to testify concerning what has been documented. It is not appropriate to document for someone else, and you should always log out of the computer prior to allowing another person to document.

The health care provider tells the client, "You are experiencing a MI," and leaves the room. The client asks the nurse what a MI stands for. What response by the nurse is most accurate?

"Myocardial infarction."

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes in to the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation?

Attach a copy of the incident report to the chart. Explanation: For legal reasons the nurse should not attach a copy of the incident report to the chart. The nurse should, however, fill out an incident report, stop the infusion and document the time, and report the error to the primary provider.

The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? Select all that apply.

Documentation must be kept of personnel who have accessed a client's record. Light boxes for examining X-rays with the client's name must be in private areas. Conversations about clients must take place in private places where they cannot be overheard. Explanation: Documentation must be kept of personnel who have accessed a client's record, light boxes for examining X-rays with the client's name must be in private areas, and conversations about clients must take place in private places where they cannot be overheard are useful strategies to limit casual access to the identity of clients and health informatics. Computer screens that are oriented toward the public view and visibly displaying clients' names on charts are incorrect, as these are breaches of patient confidentiality.

An area of specialization in nursing that is a combination of computer science, information science, and nursing science is termed:

Informatics Explanation: The goals of nursing informatics include efficiency, productivity, and effectiveness.

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. 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.

The nurse hears an unlicensed assitive personel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

Remind the UAP about the client's right to privacy. Explanation: The nurse should first remind the UAP about the client's right to privacy. All other actions are appropriate, but do not immediate protect the client's privacy.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?

subjectivity. Explanation: Quoting what the client is saying helps in the documentation of subjective data. Objective data is assessment data that may be directly observed by the nurse such as blood pressure. Organization is the structure of the documentation and does not relate to subjective data. Reimbursement is a distractor that doesn't relate to assessment data.

To which Health Insurance Portability and Accountability Act regulation should the nurse adhere when safeguarding clients' written, spoken, and electronic information?

submitting a written notice to all clients identifying the uses and disclosures of their health information Explanation: Submitting a written notice to all clients identifying the uses and disclosures of their health information is correct. The Health Insurance Portability and Accountability Act (HIPAA) protects the privacy of health records and the security of that data. Failing to recognize the client's right to withhold health information for research, releasing the client's entire health record when only portions of the information are needed, and failing to obtain the client's signature indicating that the client was informed of the disclosure of information are incorrect, as these are HIPAA violations.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?

SOAP charting Explanation: The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort 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.