29 Quiz 11 - The Nursing Process - Documenting & Recording

A nurse manager is conducting a survey of personnel to see what the general feeling is before implementing computerized charting in an acute care hospital. Which of the following would the nurse select as positive aspects of implementing this type of system? (Select all that apply.) A. The system is relatively inexpensive to maintain. B. Bedside terminals eliminate worksheets and note taking. C. The system links to various sources of client information. D. The system better protects client privacy. E. Information is legible. F. Results, requests, and client information can be sent and received quickly.

Answer: • Bedside terminals eliminate worksheets and note taking. • The system links to various sources of client information. • Information is legible. • Results, requests, and client information can be sent and received quickly. Rationale: Other positive aspects of computer documentation include the following: computer records can facilitate a focus on client outcomes; bedside terminals can synthesize information from monitoring equipment; more efficient use is made of nurses' time; monitors are linked to improve accuracy of documentation; and computer documentation incorporates and reinforces standards of care. Negative aspects of computer documentation include the following: the system is expensive; privacy may be infringed if security measures are not used; breakdowns make information temporarily unavailable; and extended training periods may be required for updates. Assessment

A nurse is employed as an MIS (medical information system) trainer at a hospital where a new computerized record system is being installed. According to the Security Rule of HIPAA, which of the following should be implemented to help ensure the security of client records? (Select all that apply.) A. Install a firewall to protect the server from unauthorized access. B. Give each unit the same password to protect the unit's information. C. Log off a terminal after using it. D. Make sure the monitor is turned away from view when unattended. E. Shred all computer-generated worksheets.

Answer: • Install a firewall to protect the server from unauthorized access. • Log off a terminal after using it. • Shred all computer-generated worksheets. Rationale: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Guidelines for confidentiality and security of computerized records also include assignment of a personal password to enter and log off computer files. The password should not be shared with anyone, including other team members. Client information should not be displayed if the terminal is unattended. Never leave a monitor unattended after logging on. Understand the facility's policy for correcting entry errors, and follow agency procedures for documenting sensitive material. Implementation

A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. A problem in documentation that may have caused the lack of reimbursement would be which of the following? A. The client's record contained an incorrect DRG. B. The client was charged for an ECG. C. A code cart opened and the client was charged for medications the client did not use. D. The physician made a diagnostic mistake.

Answer: 1 Rationale: Documentation helps a facility receive reimbursement from the federal government. The client's clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that the appropriate care has been given. Codable diagnoses, such as DRGs, are supported by accurate, thorough recording by nurses. Implementation

The nurse is doing teaching regarding medication administration for a client who is being discharged. Which of the following instructions should be rewritten for this client? A. Lasix, 20 mg, PO bid B. Lasix, 20 mg, PO twice daily C. Lasix, 20 mg by mouth, twice a day D. Lasix, 20 mg by mouth 8 AM and 2 PM

Answer: 1 Rationale: If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in layman's terms, and use of medical abbreviations should be avoided. Twice a day should be written out, not abbreviated as bid. Implementation

A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. This hospital is utilizing which of the following? A. Standardized care plans B. Traditional care plans C. Critical pathways D. Kardex

Answer: 1 Rationale: Standardized care plans were developed to save documentation time. These plans may be based on an institution's standards of practice, thereby helping to provide a high quality of nursing care. Standardized care plans are usually individualized to address each client's specific needs. Traditional care plans are written for each client, are specific, and are individualized for that client. Critical pathways are used in case management, involving a multidisciplinary approach to planning and documenting client care. The Kardex is a concise method of organizing and recording data about a client—making information quickly accessible for all health professionals. Implementation

The client states: "I really don't want anyone to visit me who has not been OK'd with me first." If utilizing SOAP format, this statement would be documented under which category? A. Subjective data B. Objective data C. Assessment D. Planning

Answer: 1 Rationale: Subjective data consist of information obtained from what the client says. When possible, the nurse quotes the client's words; otherwise, they are summarized. Objective data consist of information that is measured or observed. Assessment is the interpretation or conclusion drawn about the subjective and objective data. This is the area where the problems are documented initially. Then the client's condition and level of progress are subsequently described. Planning is the care designed to resolve the problem. Assessment

A client in long-term care is scheduled for a review of the assessment and care screening process. This assessment will be documented in which of the following? A. MDS B. OBRA C. CBE D. Kardex

Answer: 1 Rationale: The Minimum Data Set (MDS) for assessment and care screening must be performed within 4 days of a client's admission to a long-term care facility and reviewed every 3 months. Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987. It is under the OBRA law that the MDS is identified. CBE stands for charting by exception. The Kardex is a system of organizing client information so it can be accessed quickly. It is usually used in the acute care area. Implementation

A student nurse is reviewing an assigned client's chart. When trying to locate recent lab results, the student notices that each department has a separate section in the chart. This type of documentation system is called which of the following? A. Source-oriented record B. Problem-oriented record C. Case management D. Focus charting

Answer: 1 Rationale: The traditional client record is a source-oriented record in which each person or department makes notations in a separate section or sections of the client's chart. In the problem-oriented medical record, the data are arranged according to the problems the client has rather than the source of the information. Case management uses a multidisciplinary approach to documenting client care, called critical pathways. Focus charting is intended to make the client and client concerns the focus of care, utilizing a three-column format. Implementation

A client who has been hospitalized for a period of time is now being transferred to a rehabilitation center for more long-term care. As he is preparing to be discharged, the client asks the nurse if he can take his chart with them, since it's his record. The nurse responds correctly by saying: A. "You'll have to ask your doctor for permission to do that." B. "Actually, the original record is the property of the hospital, but you are welcome to copies of your records." C. "We'll make sure that all of your records are sent ahead to the rehab hospital, so you don't really have to worry about those details." D. "There's a new law that protects your records, so you're not going to be able to have access to them."

Answer: 2 Rationale: Although the client's record is protected legally as private, access to the record is restricted to health professionals involved in the client's care. The institution or agency is the rightful owner of the client's record, but the client has the right to access all information contained within his own record and to have a copy of the original record. The hospital has the right to charge a fee for the copying costs. The Health Insurance Portability and Accountability Act (HIPAA) is a law enacted to protect health information and maintain confidentiality of client records. Implementation

A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager using a critical pathway would identify this as which of the following? A. An unattainable goal B. A variance C. An incorrectly written care plan D. An error in judgment on the case manager's part

Answer: 2 Rationale: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is called a variance. Variances are deviations to what is planned in the critical pathway— unexpected occurrences that affect the planned care or the client's response to care. In this case, the client may need more time or different interventions to reach the goal. The goal and problem may be appropriate, but the interventions may need to be adjusted. Planning

The nurse administered analgesic medications to an assigned client via central line. This information should be documented in which section if using PIE charting? A. Plan B. Intervention C. Evaluation D. Progress notes

Answer: 2 Rationale: The interventions employed to manage the problem are labeled "I" and numbered according to the problem. The problem statement is labeled "P" and referred to by number. The "E" is evaluation of the effectiveness of the intervention and is also labeled and numbered according to the problem. Progress notes are not part of the identified labels of PIE charting. Implementation

A client has specific cultural needs in regard to the plan of care. This information would be found in which of the following? A. Database B. Problem list C. Plan of care D. Progress notes

Answer: 2 Rationale: The problem list is derived from the database and is usually kept at the front of the chart. The problem list serves as an index to the numbered entries in the progress notes. All caregivers contribute to the problem list, which includes the client's physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs. The database includes information about the client when admitted to the facility. The plan of care is made with reference to the active problems. Progress notes are chart entries made by all health professionals involved in a client's care. Assessment

The nurse responds to a client's call light. When entering the room, the nurse sees that the client is lying on the floor, with the bed linens around the legs. The most correctly written chart entry is: A. Client fell out of bed, but did push the call button for assistance. B. Client became tangled in the bed linens, then called for assistance after falling out of bed. C. Recorder responded to client's call light, upon entering the room, found client on floor. D. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.

Answer: 3 Rationale: Accurate notations consist of facts or observations rather than opinions or interpretations. The client was found on the floor, and the call light was activated. Those are the only things known until the nurse learns further information from questioning the client. It should never be assumed that the client fell out of bed, became tangled in bedding, or anything else. Assessment

After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why it's OK for them to review and have access to client records in the clinical area. The nurse educator responds correctly by stating that: A. "Confidentiality and privacy laws don't apply to students." B. "Most students review so many records and charts that they could not possibly remember details from any one of them." C. "Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence." D. "As long as the clinical instructor is in the area, accessing client records is part of the education process."

Answer: 3 Rationale: For purposes of education and research, most agencies allow students and graduate health professionals access to client records. The student or graduate is bound by a strict ethical code and legal responsibility to hold all information in confidence. It is the responsibility of the student or health professional to protect the client's privacy by not using a name or any statements in the notations that would identify the client. Implementation

A nurse works in a hospital that utilizes a charting by exception documentation system. When providing care and performing assessments, the nurse may not address all of the sections on a client's flow sheet, especially if the client did not require this particular care. In order for the nurse to identify that these areas were addressed, but no care was needed, the best action is to: A. Leave them blank. B. Leave them blank, but then add an extensive explanation in the progress notes section of the chart. C. Write N/A on the flow sheet in the areas that are not applicable to that client. D. Make sure this information gets passed along in the shift report.

Answer: 3 Rationale: Many nurses are uncomfortable with the CBE system and believe that if something was not charted, it was not done. A suggestion to address this would be to write N/A on the flow sheets where the items are not applicable to the client, and not leave the spaces blank. This would avoid the possible assumption that the assessment or intervention was not done by the nurse. It is never a good idea to leave blanks in any charting area. Passing information along in the report is a good way to ensure continuity of care for clients, but this would only be an oral report, not written documentation. Implementation

A nurse makes an entry in a client's chart that includes documentation about the routine care, assessment findings, and client problems. This documentation is arranged in a chronological order, from the time the nurse started the shift until the nurse entered the documentation in the client's record. This is an example of which of the following? A. Problem-oriented recording B. Source-oriented recording C. Narrative charting D. Plan of care

Answer: 3 Rationale: Narrative charting is a traditional part of the source-oriented record. It consists of written notes that include routine care, normal findings, and client problems. There is no right or wrong order to the information, although chronological order is frequently used. Problem-oriented recording is arranging the data according to the problem the client has. Source-oriented recording is arranged in separate sections for each department that contributes to the client's care. Plan of care is part of the problem-oriented medical record. Implementation

The client is brought to the emergency department by the police. There are numerous large areas of bruising around the client's throat and upper arms, the client's lip is cut, and the client's clothes are ripped. The documentation that is most correctly written for this situation is: A. Client brought to the ED, victim of some type of abuse, in the custody of the police. B. Client had areas of bruising on throat and upper arms-as if someone had choked the client-clothing ripped. C. Client brought to ED by police. Bruising to throat and upper arms, measuring ____ to _____ cm. Clothes ripped. D. Police brought client to the ED after getting beat up. Clothes ripped, bruising to throat and upper arms. Lip cut.

Answer: 3 Rationale: Notations on records must be accurate and correct. Accurate notations consist of facts or observations rather than opinions or interpretations. Data should be specific. In this case the bruises would be measured and measurements recorded, or pictures could be taken according to some departments' policies. Assuming that the client is a victim of abuse, or that the client had been beaten or choked is opinion and interpretation, not fact and observation. Implementation

A nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording. In looking for the most recent physician orders, the nurse should look in which section? A. Database B. Problem list C. Plan of care D. Progress notes

Answer: 3 Rationale: The initial list of orders or plan of care is made with reference to the client's active problems in this type of charting. Physicians write physician orders or the medical care plan. Nurses write nursing orders or the nursing care plan. The database consists of all known information about the client upon admission. The problem list includes those identified problems, listed in the order in which they are identified. Progress notes are chart entries made by all health professionals involved in the client's care. Assessment

At the end of the shift, the nurse is reviewing client documentation for the shift. Among the documentation entries the nurse checks, special attention is paid to the flow sheets and abnormal assessment findings for each client. This type of charting is an example of which of the following? A. Computerized documentation B. Focus charting C. SOAP charting D. Charting by exception

Answer: 4 Rationale: Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE. Computerized documentation is a way to manage the volume of information required in a client's chart, and different systems may include a variety of setups and programs. Focus charting is organized into data, action, and response sections, referred to as DAR. SOAP charting is a way to organize data and information in the client's record: S 5 subjective data; O 5 objective data; A 5 assessment; P 5 plan. Evaluation

A nursing student has been assigned to a specific client for one of the clinical experiences on a surgical unit. Before the clinical experience begins, the student must be aware of the client's pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information in order to provide the most appropriate care during the shift. In order to help the student save time in researching all of this information, what should be the first place to start the review? A. The client's medical record B. The MAR (medication administration record) C. The written care plan D. The Kardex

Answer: 4 Rationale: The Kardex is a concise method of organizing and recording data about a client, making information quickly accessible to all health professionals. The system is on either an index-type file or a computer-generated form. Information is usually organized into sections: client history/information, list of medications, IV fluids, daily treatments and procedures, diagnostic procedures, allergies, how the client's physical needs are met (type of diet, bathing needs, etc.), and a problem list with stated goals. The medical record contains this same type of information and the Kardex is included in the record at discharge, but the complete chart is lengthy and would take the student more time to review. The MAR includes only those medications that are prescribed or scheduled to be administered during the client's stay. It would not include other information like diagnostic tests, daily cares, and so on. The written care plan may be included in the Kardex, or at least a portion of the care plan, but it would not be as inclusive as the Kardex. Assessment

After completing the clinical and documenting in the progress notes, the nursing student discovered he had written in the wrong chart. The correct action is to: A. Use white-out over the mistake. B. Take a wide permanent marker and blacken out all the documentation. C. Put an "X" through the entire page, identify it as an "error," initial, and move on to the correct chart. D. Draw a single line through the documentation, write "mistaken entry" next to the original entry, and initial it.

Answer: 4 Rationale: When a mistake is recorded, a line should be drawn through it and the words "mistaken entry" written above or next to the original entry, then initial or signature— whichever is agency policy. The original entry must remain visible. Erasure, blotting out, or correction fluid should not be used. Implementation

The client, after receiving emergency treatment for an acute asthma attack, had diminished wheezing in both lungs. When utilizing focus charting, this information would be included in the _______________ section.

Answer: response Rationale: Focus charting is intended to make the client and client concerns and strengths the focus of care. The progress notes are organized into data (D), action (A), and response (R). The response category reflects the evaluation phase of the nursing process and describes the client's response to any nursing and medical care. The data section reflects the assessment phase of the nursing process and consists of observations of client status and behaviors, including data from flow sheets. The action category reflects planning and implementation and includes immediate and future nursing action. Evaluation