Chapter 3: Documentation EAQ

Which statement regarding the importance of documentation is correct?

"Failure to document patient care may result in the loss of reimbursement of funds from government and other agencies"

Which statement for the nurse regarding documentation requires correction?

"I should document in the patient's medical record with red ink"

Which finding in a patients medical record indicates the need for staff education on proper documentation practices?

"Status is unchanged"

When a visitor asks the nurse details about a patient who was discharged, which response by the nurse is best?

"I am not permitted to share information about the patient unless you have written permission"

Which statement by the nursing student indicates a need for additional teaching?

"Medications are to be charted immediately before I administer them"

Which statement demonstrates assessment according to SBAR documentation?

"Mr. Jones presents with epistasis and significant bruising to the arms."

In which ways does complete and accurate documentation benefit the health care facility? Select all that apply.

Health care facility will receive insurance reimbursement for services rendered Health care facility has documentation to support quality of care in the event of a lawsuit Health care facility may use patient data to identify areas of possible improvement

When is the best time for a nurse to document patient care?

As soon as possible after completion of care

During which phase of the nursing processes does provision of nursing care take place?

Implementation

Which data would the nurse include in documentation of patient care? Select all that apply.

Time of care Patient's pain level Type of procedure performed

A nurse on the evening shift reviews a chart and finds that the patient did not receive a morning dose of insulin as prescribed. After notifying the charge nurse, which nursing action is priority?

Complete an incident report according to hospital policy

A health care facility uses problem-oriented medical record (POMR) charting for documenting patient records. The new nurse manager feels that the word "problem" can carry negative connotations. Which charting method can the nurse manage suggest as an alternative, keeping in mind that minimal structural change can be made?

Focus charting

When reviewing charting documented using the SOAPE model, which entry under the "S" portion of the model requires correction?

"Patient reports pain level of 8 out of 10 during dressing changes"

Which statement is best for the nurse to chart regarding a patient using a walker?

"The patient walked the entire stretch of the hall using the walker without any problems."

Which characteristic of electronic health records (EHRs) accurately describes how they differ from electronic medical records (EMR)?

Ability to exchange patient data with other facilities

The nurse is unable to insert an intravenous (IV) line and asks a coworker to complete the insertion. Which action should the nurse perform after the has inserted the IV?

Ask the coworker to document the IV line insertion

Which instructions would the nurse follow in an effort to maintain patient confidentiality? Select all that apply.

Be vigilant in keeping documents in a safe place when in the clinical agency Avoid leaving papers with patient identifiers in the nurses' station or conference room Within the facility, guard at all times documents with patient identifying information

Which step should the nurse take immediately before a patient is transported to surgery?

Chart the time the patient left and the method of transport

At the beginning of the shift, the nurse charts a complete assessment, observations, intravenous (IV) site and rate, vital signs and other pertinent data, but during the remainder of the shift, only additional treatments withheld, new concerns, and changes in condition are charted. This reflects which form of charting?

Charting by exception (CBE)

Which action would the nurse take when documenting?

Clearly indicating goal-directed nursing care

When collecting a patient's valuables before surgery to be turned over to security for safekeeping, which would be included in the documentation accompanying the items?

Gold-colored smart watch with white band

Which finding in patient medical records indicates the need for staff education on documentation?

Incident report and findings related to a fall

When caring for a patient with pneumonia, which information would the nurse refrain from documenting in the patient's chart?

Is not listening to information

Which statement regarding information included in the Kardex system is true?

It covers the medication list without citing details of allergies.

Which statement regarding the health care record is true? Select all that apply.

It is a legal document It may be used in the accreditation process It may be electronic, paper, or a combination of both It is used as a reference for reimbursement of health care costs It facilitates accurate communication and continuity of care among members of the health care team

Which request for documentation would the unit Secretary question before sending it outside the organization?

Laboratory results to an outside research institute

Which finding during review of nursing documentation indicates the need for staff education? Select all that apply.

Leaving spaces between narrative entries in the medical record Charting abbreviations and medical terminology not on an approved list Documenting that a health care provider refused to change inappropriate order

Which action requires correction regarding patient confidentiality?

Make copies is medication lists to review privately at home

Which action by the licensed practical nurse (LPN) would lead to the license being revoked?

Not shredding papers containing the patient's identity before leaving the hospital

When a nurse forgets to chart a procedure and returns to the chart later, several entries have already been written by other nurses. Which action by the nurse indicates an understanding of charting guidelines?

Note that the entry is late and enter the details according to the hospital policy

Which information would the nurse keep in mind while documenting a patient's health information in the patient's records? Select all that apply.

Only hard-pointed, permanent black ink pens should be used Only the patient findings that have been observed by the nurse should be documented Such phrases as "status unchanged" or "had good day" should not be used

When documenting with the charting by exception method, which acronym is generally used?

PIE (Problem, Intervention, Evaluation)

Which term is defined as an appraisal by a professional coworker of the manner in which an individual nurse conducts practice, education, or research?

Peer review

Which action would serve as defense against legal claims associated with nursing care?

Perform clear and precise documentation of goal-directed nursing care given

Which method of patient charting follows the SOAPIER format?

Problem-oriented medical record (POMR) charting

A patient has an accidental fall in a wet and slippery floor in the hospital. Which information would the nurse include in the incident report? Select all that apply.

Reason for the patient's fall Name of the patient who had fallen Name of the health care provider who attended to the patient after the fall

Which individual is responsible for completing a patient's initial admission nursing history, perform the physical assessment, and develop the care plan?

Registered nurse (RN)

While documenting in the process notes, the nurse updates only the data and action components. Which component of the focus charting system did the nurse miss documenting?

Response

Which acronym represents the approach of documenting implementation and evaluation in the patient progress notes?

SOAPIER

Which action is priority for the nurse to take next when documenting in a patient's electronic medical record and the health care provider requests the nurse make rounds?

Saving data and logging out of computer

Which method of patient charting is created from assessment findings?

Source-oriented (narrative) charting

Which information is important for the nurse to document in the medical record when transferring a patient?

Time leaving and mode of transportation

The nurse manager is preparing an in-service for unit states after observing that the nursing notes in several charts during an audit were lengthy and irrelevant. Which strategies can the nurse manager teach the staff to use to improve charting quality? Select all that apply.

Use approved abbreviations Use standard symbols and acronyms Shorten sentences to matter-of-fact statements

Which finding indicates the need due additional stated education regarding documentation?

Use of correction fluid to fix errors