Chapter 19: Documenting and Reporting
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."
Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing?
Nutritional consult
The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?
Reporting
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:
have the right to copy their health records.
With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.
identifying demographics, including diagnosis current orders any abnormal occurrences with the client during the shift
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:
interpretation of data.
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
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
The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?
Inform the health care provider that a written order is needed.
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.
Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?
Omitting clients' responses to nursing interventions
The nurse hears an unlicensed assistive personnel (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.
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
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.
Which example may illustrate a breach of confidentiality and security of client information?
The nurse provides information over the phone to the client's family member who lives in a neighboring state.
The nurse is providing documentation for the care rendered to clients. Which characteristics identify documentation as effective? Select all that apply.
Thoughtful Readable Timely Clear, concise, and complete
A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate?
Write a narrative note in the designated nursing section.
A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication?
"I think the client would benefit from intravenous furosemide."
A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?
Calling the client information desk to find out the room number of the family member
A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate?
"Any information that can identify a person is considered a breach of client privacy."
The parents of a hospitalized 10-year-old 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."
Which note includes all elements of a SOAP note?
Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.
A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents?
Client's record and occurrence report
The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error?
Create an addendum with a correction.
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 declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?
those directly involved in the client's care
A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse?
"Legal policy requires nursing practice to be permanently integrated into the client record."
The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?
"Only authorized persons are allowed to access client records."
The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?
"Will you prescribe a complete blood count to check the white blood cell count and a culture?"
The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states:
Although not written, the nurse must know or question the rationale before performing an action.
A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information?
Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."
Which statement is not true regarding a medication administration record (MAR)?
If the client declines the dose, the nurse does not have to document this on the MAR.
The nurse is documenting a variance that has occurred during the shift. 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
A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client 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
A nurse is documenting care for an older adult client who is recovering from a mild stroke. Which documentation entry(ies) follows the recommended guidelines for communicating and documenting client information? Select all that apply.
The client rates pain as 2 compared to a 7 yesterday. Radial pulse 72 beats/min, strong and regular.
The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise?
SBAR
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
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 the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the 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
A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as?
A variance
Which are appropriate actions for protecting clients' identities? Select all that apply.
Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.
The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?
subjectivity
