PrepU- Documenting and Reporting
The nurse is documenting morning care for a pt with diabetes. Which documentation is most appropriate for this client?
0800 consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10
Which principle should guide the nurses documentation of entries on the clients health care record?
Precise measurements should be used rather than approximations.
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 nurse to provider interaction correctly utilized the SBAR format for improved communication?
"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250. And I'm wondering if you would like to adjust the sliding scale insulin."
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."
The nurse is caring for a client who requests to see ones medical record since admission to the hospital. What is the appropriate response by the nurse?
"I will have to review the policy that determines what procedure is in place for client access."
Which is the proper way to document midnight in a clients record?
0000
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. It's a 7 out of 10"
Which are appropriate actions for protecting clients identities?
Document all personnel who have accessed a clients record.
What dual purpose does an audit serve?
Quality assurance and reimbursement
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.
When recording data regarding the clients health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan of care of the client which of the following styles of documentation is the nurse implementing?
SOAP CHARTING
Which finding from a nursing audit reflects high standards for client safety and institutional health care?
The nurse documents clients' responses to nursing interventions.
A nurse he caring for a client diagnosed with myocardial infarction. A person identifying himself as the clients friend asks the nurse for the clients records, but the nurse declines. The nurses unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access the clients records?
Those directly involved in the clients care
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
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
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 clients records
A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment?
the lower extremities
The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?
urine output 100 ml
