Sherpath: Documentation Quiz

A nursing student asks an instructor why documentation in the medical record is so important. Which statements of the instructor describe the advantages of documentation in nursing?

-Documentation is essential for reimbursement. -Documentation may provide protection from malpractice. -Documentation assists in identifying and justifying nursing interventions.

A nurse, after administering antibiotics, is updating a patient's chart in the emergency room. What elements of the report does the nurse accurately document in order to limit the nursing liability in case of a legal claim?

-Drug allergies. -Discontinued medications. -Current medications given.

A nurse manager is educating the nursing staff on the importance of security with the implementation of the (EHR) on the unit. What points does the manager emphasize?

-Do not share passwords with anyone. -Do not log in with someone else's user access. -Do not leave the patient's medical record open on a computer screen.

An elderly patient in a long-term care facility complains of abdominal pain. The patient has been on calcium supplements for the past 3 years. The patient worked as a flight attendant for an airline several years before, and she traveled to Egypt many times in her youth. She also has had liposuction. Which components of this information should the nurse include in the nursing minimum data set (NMDS)?

-Abdominal pain. -Calcium supplements. -History of liposuction. -Occupation: flight attendant.

Which behaviors indicate a nurse has information literacy?

-Ability to recognize the need for information. -Ability to locate and use information effectively. -Ability to select and evaluate needed information.

A nurse is caring for a patient who is diagnosed with renal failure due to diabetes. The nurse documents the patient care summary in the Kardex file. Which information about the patient would the nurse have to document in this file?

-Allergies. -Emergency code status. -Factors related to activities of daily living.

A new licensed practical nurse is typing confidential patient information into a computer-based record system. Which instructions should the registered nurse provide the licensed practical nurse for safe and effective electronic health record documentation?

-Always log off the computer after completing the documentation. -Review the documentation guidelines for better understanding. -Ensure that the entry screens are not visible to others in the area.

A nurse working in the United States teaches students, supervises the use of information systems, designs systems, and uses data to establish best-practice guidelines. What certifications might the nurse aim to receive?

-American Nurses Credentialing Center (ANCC). -Health Care Information and Management Systems Society (HIMSS).

A patient complains of not feeling well and is coughing frequently with copious phlegm. Coughing is worse at night. During the initial assessment; the nurse finds that the patient coughs violently for 40 to 45 seconds with thick yellow phlegm. The blood pressure is 150/90 mm Hg; pulse rate is 92 beats/min, and respiratory rate is 22 breaths/min. Wheezing and rhonchi are present in both lung bases. The patient expresses having chest pain when coughing and the pain radiates to the arm. Which data should the nurse document as objective data?

-Blood pressure. -Thick yellow phlegm. -Presence of wheezes and rhonchi.

A patient is diagnosed with acute renal failure due to diabetes. Following treatment, the patient recovers. The patient is being discharged to home on insulin. The nurse is preparing a discharge summary for the patient. What information should the nurse provide in the discharge summary?

-Contact information of the health care provider. -Step-by-step instructions for self-administration of insulin. -Signs and symptoms that have to be reported to the health care provider.

The nurse is caring for a patient who has returned to the floor after a knee replacement in the morning. Which statements written in the nurse record are accurate?

-Heart rate: 75/min, Urine voided 300 mL, pain rated as 7 on a scale of 0-10. -Temperature: 102 degrees Fahrenheit at 5 PM, Paracetamol (Tylenol) 500mg at 5pm, Temperature 99 degrees Fahrenheit at 6:30 pm.

Which information does the nurse educator include in a class about the advantages of nursing informatics? Select all that apply.

-It increases patient safety. -It improves clinical processes. -It reduces documentation time. -It improves the process of patient care.

How is the use of telemedicine beneficial to the patient?

-It is cost-effective. -It helps in achieving good treatment outcomes. -Its use increases patient satisfaction.

Which statements by the nurse indicate a correct understanding for the initiatives of the Technology Informatics Guiding Education Reform (TIGER)?

-It requires nurses to be competent in informatics. -It address informatics for safe, patient-centered care. -It includes management and leadership as a nursing skill.

A nurse spends a considerable amount of quality time documenting pertinent clinical patient data accurately and comprehensively. What does effective documentation ensure?

-It saves time of the physician and other members of the health care team. -It provides continuity of care. -It minimizes the risk of errors. -It protects the nurse from legal issues. -It facilitates proper insurance reimbursement.

Which areas of focus are included as vision pillars for the Technology Informatics Guiding Education Reform (TIGER) initiative?

-Management. -Communication. -Policy and culture.

A nurse is caring for a patient who is diagnosed with renal failure due to diabetes. The nurse has to pass the patient care to another nurse during change of shift. Which information should the nurse include in the hand-off report?

-Nursing diagnosis of the patient. -Important information about family members. -Recent changes in objective measurements.

A medical center uses all electronic charting and has no paper records. Which health care professional would initiate an order for a medication to treat a respiratory infection?

-Primary health care provider.

The nurse is learning about Subjective-Objective-Assessment-Plan (SOAP) charting. In which ways does SOAP charting differ from Problem-Intervention-Evaluation (PIE) charting?

-SOAP charting originates from medical records. -SOAP charting includes assessment information.

A nurse is caring for a patient who has been diagnosed with pneumonia. The nurse is reviewing the assessment details of the patient. Blood pressure is 150/90 mm Hg; pulse is 92 beats/min; respiratory rate is 22 breaths/min. The patient seems to have difficulty breathing. Sounds are produced when the patient exhales. Auscultation reveals rhonchi in the lower lung bases. Copious amounts of phlegm are produced since morning. A senior nurse finds this to be poor quality of documentation. Which statements in the documentation are considered to be poor quality reporting?

-Sounds are produced when exhaling. -The patient seems to have difficulty breathing. -Copious amounts of sputum produced since morning.

A nurse assesses a patient postoperatively and charts the findings in a SOAP note. What elements are integral to the SOAP note?

-Subjective. -Assessment. -Objective. -Plan.

A patient complains of not feeling well and is coughing frequently with copious phlegm. The nurse administrator tells the patient's nurse to be more cautious when charting errors. Which errors in documentation done by the staff nurse is the nurse administrator referring to?

-The nurse's handwriting is not legible. -The nurse has not documented the discontinued medications.

The nurse is teaching a patient how to evaluate the validity of information on a health related website. What does the nurse include in the teaching plan?

-The website must be updated on a regular basis. -The footnotes should indicate the sources of information. -The information should be available on other websites. -The websites should have an equal distribution of text and images.

A patient sustains an injury from a fall while on a hospital unit. The nurse makes an incident report. What is the purpose of the incident report?

-This report helps in providing good quality health care. -This report helps to identify the need to change a procedure or policy. -This report helps in identifying loopholes in the operation of the health care system.

A nurse is administering an enema to a patient. What should the nurse record after the procedure?

-Time at which enema is administered. -Equipment used for administration.

Which documentation system includes realistic patient- and family-centered outcomes?

Case management charting.

The student nurse is learning about the various formats of documentation. Which statement should the nurse identify as the full form of the DAR format of problem-oriented medical recording?

Data, Action, Response.

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note?

Enter only objective and factual information about the patient.

What information does the nurse include when teaching a group of patients about health concepts?

Methods to evaluate healthcare blogs.

Which of the following charting entries is most accurate?

Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.

What is an appropriate way for a nurse to dispose of printed patient information?

Place in a secure canister marked for shredding.

Which technology can the nurse use to deliver emergency interventions when the primary health care provider is not available in the emergency room?

Telemedicine.

A patient who underwent abdominal surgery reports to the nurse, "I have a sharp and intense pain around the umbilicus." The patient rates the pain as 9 on a scale from 0 to 10. The nurse documents it as "The patient has abdominal pain, and feels uncomfortable." Which statement best describes the nurse's documentation?

The documentation lacks accuracy.

What is the focus of nursing informatics in the health care system?

The management and communication of data and information.

The licensed practical nurse is assisting a patient in ambulation. The registered nurse who assigned the task to the licensed practical nurse witnesses the patient suddenly falling. Who is responsible for documenting the patient incident report?

The registered nurse.

A patient was shifted from the intensive care unit to the cardiac unit. What kind of reports are used to communicate between the two units?

Transfer reports.

A patient shows the nurse a website that recommends weight loss medications. What question does the nurse ask the patient in order to evaluate the authority of the website?

Who are the authors, sponsors, and publisher?

You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet?

You need to use words the patient can understand when writing the directions.