Chapter 20: Documenting and Reporting
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? -"The electronic health record we use does not allow us to use different formats." -"Legal policy requires nursing practice to be permanently integrated into the client record." -"It would be easier to do it that way. You could develop a tool to use." -"The facility requires us to document client care this way because of the computer application used."
"Legal policy requires nursing practice to be permanently integrated into the client record." Explanation: Legal policy requires nursing care documentation to be permanently integrated into the client record. Computer applications and electronic health record formats may have some differences, but they all use an integrated record. Suggesting that the nurse develop a new tool would be inappropriate, as separate nursing documentation would not be legal.
A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and: -reimbursement. -research. -staff development. -change of mechanisms.
reimbursement. Explanation: Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits do not play a role in staff development, research, or change of mechanisms within a system.
The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? -pain rating of 4 on a scale of 0-10 -urine output 100 ml -concerned with feeling tired -describes wound as itchy
urine output 100 ml Explanation: Objective data, such as the measurable urine output, are collected by the nurse. Subjective data, such as feeling pain, itchiness, or fatigue, are reported by the client.
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 -A sentinel event -An audit -A never event
A variance Explanation: This scenario reflects a variance in care. 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 and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client.
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. -Add the new order to the medication administration record. -Write the order in the client's record. -Call the pharmacy to have the order entered in the electronic record.
Inform the health care provider 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 health care provider to write the order.
A new graduate is working at a first job. Which statement is most important for the new nurse to follow? -Only document changes in the client's status. -Use abbreviations approved by the facility. -Document lengthy entries using complete sentences. -Use PIE charting, even if it is not the institution's charting method.
Use abbreviations approved by the facility. Explanation: Use abbreviations, but only those that are commonly accepted and approved by the facility. All documentation requires proper grammar and writing techniques. The nurse should be using the particular charting method for the employing institution. All care and observations should be documented - not only changes in a client's status.
A client is scheduled for a CABG procedure. What information should the nurse provide to the client? -"A complete ablation of the biliary growth will decrease liver inflammation." -"A coronary artery bypass graft will benefit your heart." -"The CABG procedure will help identify nutritional needs." -"The CABG procedure will help increase intestinal motility and prevent constipation."
"A coronary artery bypass graft will benefit your heart." Explanation: Coronary artery bypass graft is abbreviated CABG. It does not identify nutritional needs, decrease liver inflammation, or increase intestinal motility.
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? -"You may continue to post about a client, as long as you do not use the client's name." -"The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family." -"All aspects of clinical practice are confidential and should not be discussed." -"Any information that can identify a person is considered a breach of client privacy."
"Any information that can identify a person is considered a breach of client privacy." Explanation: Any information that can identify a person is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the facility and unit is disclosed in the post. Discussion of clinical practice can be helpful for learning purposes or seeking advice on care. No care should be discussed, even privately, with friends and family without first obtaining the client's permission.
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." -"I am calling about the client in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." -"I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." -"I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."
"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 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." -"I am sorry I can't access that information." -"Let me get that for you." -"The provider will need to give permission for you to review."
"Only authorized persons are allowed to access client records." Explanation: The client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. The other answers are therefore inappropriate responses.
Which abbreviation is correct for use in documentation? -PO -Per os -Sub q -BT
PO Explanation: Facilities develop acceptable abbreviation lists based on guidelines from oversight agencies. PO, which is a derivative abbreviation from the Latin term "per os," signifying "orally" or "by mouth," is a commonly approved abbreviation. "Sub q" (meaning "subcutaneous"; SC is preferred), "Per os" (meaning "orally" or "by mouth"; PO is preferred), and "BT" (meaning "bedtime"; can be confused with "BID," meaning "twice daily") are not generally accepted abbreviations.
Which note includes all elements of a SOAP note? -Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. -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. -Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. -Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess.
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. Explanation: A SOAP note consists of subjective information, objective information, an assessment, and a plan. The correct response includes each of these while the remaining three responses are each lacking a different one of the components.
Which are appropriate actions for protecting clients' identities? Select all that apply. -Orient computer screens toward the public view. -Have conversations about clients in private places where they cannot be overheard. -Ensure that clients' names on charts are visible to the public. -Place light boxes for examining X-rays with the client's name in private areas. -Document all personnel who have accessed a client's record.
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. Explanation: Documenting all personnel who have accessed a client's record, placing light boxes for examining X-rays with the client's name in private areas, and having conversations about clients take place in private where they cannot be overheard are useful strategies to limit casual access to the identity of clients and health informatics. Orienting computer screens toward the public view and visibly displaying clients' names on charts are incorrect, as these are breaches of client confidentiality.
According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? -Psychomotor skills -Documentation -Clinical judgment -Accreditation
Documentation Explanation: Documentation is the primary source of evidence used to measure performance outcomes, according to the CNA. Accreditation is the process whereby educational institutions are evaluated and, if approved, certified by a third party to validate their competency. Psychomotor skills are skills that require physical actions and muscular coordination to perform. Clinical judgment is an attribute of health care professionals that involves the use of critical thinking, intuition, and clinical experience when making a decision about a client's care to achieve the best outcome for the client.
Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? -Recording nursing interventions -Omitting clients' responses to nursing interventions -Documenting clients' health histories and discharge planning -Identifying nursing diagnoses or clients' needs
Omitting clients' responses to nursing interventions Explanation: Omitting clients' responses to nursing interventions is correct because it does not fit the criteria for legally defensible charting. Recording nursing interventions, identifying nursing diagnoses or client needs, and documenting clients' health histories and discharge planning are all criteria for legally defensible charting and would demonstrate evidence of quality care.
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? -Report the UAP to the nurse manager. -Document the UAP's conversation. -Notify the client relations department about the breach of privacy. -Remind the UAP about the client's right to privacy.
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 immediately protect the client's privacy.
Which organization audits charts regularly? -National League for Nursing -American Nurses Association -The Joint Commission -Sigma Theta Tau International
The Joint Commission Explanation: The Joint Commission (TJC)audits client records regularly under specific guidelines that are announced annually and shared with each institution. TJC also encourages institutions to set up ongoing quality assurance programs. The National League for Nursing, American Nurses Association, and Sigma Theta Tau International are professional nursing organizations that provide services to nurses; they do not access client records. .
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: -relevant data. -factual statement. -important information. -interpretation of data.
interpretation of data. Explanation: A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today.
The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? -reimbursement -subjectivity -objectivity -organization
subjectivity Explanation: Quoting what the client is saying helps in the documentation of subjective data. Objective data are 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.
