Fundamentals Nursing Prep U Chapter 16 Documenting, Reporting, Conferring, and Using Informatics
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 nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development?
"The care plan is required for every client by the Joint Commission."
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."
A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which information would the nurse expect to include when preparing the verbal handoff report?
Current client assessment
The nurse mistakenly documented one client's assessment data on another client's health care record. What action should the nurse take?
Draw a single line through the error, initial it, and write the correct entry
It is acceptable for the nurse to accept a verbal order from the physician in which situation?
During a medical emergency
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.
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.
A nurse documents the following client data in the patient 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 client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?
Accurately documenting client care on the client record
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
What is the primary purpose of the client record?
Communication
A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?
a client who is homebound and needs skilled nursing care
A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?
Graphic sheets
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
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
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
What situation would permit the nurse to disclose information without the client's approval?
the nurse suspecting that a client is being abused or neglected
Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.
• obscuring identifiable names of clients and private information about clients on clipboards • placing fax machines, filing cabinets, and medical records in areas off-limit to the public • keeping record of people who have access to clients' records
The nurse is in the process of reporting to the health care provider the changes in the client's status. What is the best action by the nurse? Select all that apply.
• showing the provider the trends from baseline to present in blood pressure • informing the provider of the client's present heart rate of 116 BPM • faxing the results of blood chemistry levels to the provider's office
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."
Which charting formats permit documentation on any significant topic, not just client problems?
FOCUS
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."
A nursing student is preparing a presentation on client records and documentation. What information should the student include in the presentation?
Communication is the primary purpose of client records.
A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis?
public health department
A nurse is documenting care for clients in a hospital setting. Which documenting errors may potentially increase the nurse's risk for legal problems? Select all that apply.
• The content is not in accordance with professional standards. • There are lines between the entries. • Dates and times of entries are omitted.
The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?
Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.
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."
Which flow sheet provides the health care provider with information on an ongoing record of fluid loss?
Intake and output graphic sheet
What dual purpose does an audit serve?
Quality assurance and reimbursement
A nurse is preparing an educational session on the purpose of documentation in health care 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
Which clinical situation 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.
The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate?
"The benefit of CBE is less time needed on computer charting."
The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr, The client is NPO and has received Morphine sulfate 4 mg IV for pain with a decrease of epigastrc pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method?
4/10 pain on pain scale, epigastric pain; with reports of nausea
The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?
Reporting
Which statement regarding FOCUS charting is most accurate?
The charting focuses on client strengths, problems, or needs.
A nursing student is attending a clinical rotation in a labor/deliver/postpartum unit and is able to see a vaginal delivery for the first time. The student takes a picture of the newborn and posts it on a social media website. What action may occur related to this privacy violation?
The student may be dismissed from the nursing program as well as fined for a HIPAA violation.
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:
have the right to copy their health records.
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:
interpretation of data
The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which of the following should the nurse record in his charting? Select all that apply.
• Client is crying • Client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today."