Ch19: Documenting+Reporting

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate? "CBE is a relatively new format of documentation in electronic health records." "The benefit of CBE is less time needed on computer charting." "CBE is the best way to protect against lawsuits." "The benefit of CBE is that it demonstrates whether high-quality care is given."

"The benefit of CBE is less time needed on computer charting."

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? Occurrence report and critical pathway Critical pathway and care plan Care plan and client's record Client's record and occurrence report

Client's record and occurrence report An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.

Which charting format permits documentation on any significant topic, not just client problems? FOCUS PIE SOAP CBE

FOCUS

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator? Translators may need additional explanations of medical terms. Talking directly to the translator facilitates the transfer of information. Talking loudly helps the translator and the client understand the information better. It is always okay to not use a translator if a family member can do it.

Translators may need additional explanations of medical terms.

What dual purpose does an audit serve? quality assurance and reimbursement education and confidentiality communication and evaluation knowledge and quality

quality assurance and reimbursement Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits have no role in communications, evaluation, knowledge, quality, education, or confidentiality,

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? "The CABG procedure will help increase intestinal motility and prevent constipation." "The CABG procedure will help identify nutritional needs." "A coronary artery bypass graft will benefit your heart." "A complete ablation of the biliary growth will decrease liver inflammation."

"A coronary artery bypass graft will benefit your heart."

A nurse is giving a verbal report to a health care provider using the ISBAR communication technique. The client being discussed has signs and symptoms of fluid volume deficit. Which statements should the nurse include in the report? Select all that apply. "Current blood pressure is 90/50 mm Hg with a pulse of 112 bpm." "I am the nurse assigned to the client." "All of the orders have been completed." "The client vomited twice and has dry mucous membranes." "The client reports dizziness when walking." "I've documented all the care, including the vital signs."

"Current blood pressure is 90/50 mm Hg with a pulse of 112 bpm." "I am the nurse assigned to the client." "The client vomited twice and has dry mucous membranes." "The client reports dizziness when walking." "All of the orders have been completed." All of the information is appropriate except the comment about documenting the care. ISBAR includes identifying oneself, situation, background, assessment, and recommendation.

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? "I am calling because the client receiving blood has developed dyspnea and had crackles." "This client has a medical history of heart failure." "I think the client would benefit from intravenous furosemide." "It seems like this client has fluid volume overload."

"I think the client would benefit from intravenous furosemide." Situation, background, assessment, and recommendations (SBAR) provides a consistent method for hand-off communication that is clear, structured, and easy to use. The S (situation) and B (background) provide objective data, whereas the A (assessment) and R (recommendations) allow for presentation of subjective information. Calling to report dyspnea and crackles occurs as the nurse describes the situation. Providing the medical history occurs as the nurse offers important background information. Stating that the client has fluid volume overload is the assessment of the nurse. Stating that the nurse thinks the client would benefit from intravenous furosemide is the nurse's recommendation.

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? "Are you questioning the care of your child?" "No, the physician will not give you access to review the records." "I will arrange access for you to review the record after you put your request in writing." "Only the client has the right to review the health care records."

"I will arrange access for you to review the record after you put your request in writing." Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. Because the child is a minor, it is the parents' right to view the client's record. Therefore, the statements about the physician not giving the parents access to review the records and asking if the parents are questioning the care of their child are incorrect.

The nurse is caring for a client who requests to see one's 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." "Let me open up the computer access so that you can see what information is of interest to you." "You may not understand all of the information and it will confuse you so I will help you decipher it all." "The hospital owns your records and does not have to allow you access while you are a client here."

"I will have to review the policy that determines what procedure is in place for client access."

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? "It will let me see everything that has been done and things that need to be done." "It will give me a better sense of what my workload will be today." "It will allow for us to see the client and possibly increase client participation in care." "It makes our client feel like we care, especially if we start the day off with a clean room."

"It will allow for us to see the client and possibly increase client participation in care." Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? "Let me get that for you." "Only authorized persons are allowed to access client records." "I am sorry I can't access that information." "The provider will need to give permission for you to review."

"Only authorized persons are allowed to access client records."

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records? "The clients' medical records are an obstruction to research and education." "I can share the clients' medical records with the health care team." "The clients' medical records provide data for legal evidence." "The clients' health records should be used to promote reimbursement from insurance companies"

"The clients' medical records are an obstruction to research and education."

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1"I don't feel well. I've been urinating often, and it burns when I urinate." 2Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. 3Fever, possible urinary tract infection 4Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

1"I don't feel well. I've been urinating often, and it burns when I urinate." 2Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. 3Fever, possible urinary tract infection 4Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

The nurse is tasked to organize weekly care plan conferences with other health care team members. Which would be appropriate items to include in this meeting? Select all that apply. A conversation addressing the need for durable medical equipment when the client goes home A discussion of the meal plan for a client with diabetes A review of a client's current progress in the plan of care A recommendation for pain management by the emergency department physician who admitted the client a week ago A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made

A conversation addressing the need for durable medical equipment when the client goes home A discussion of the meal plan for a client with diabetes A review of a client's current progress in the plan of care A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made Care plan conferences are discussions about client care, usually involving several disciplines. Interdisciplinary conferences help to coordinate services so that the client's plan of care can be developed and implemented in the most efficient way. Nurses may initiate these conferences and invite members of the health care team from other departments (e.g., physical therapy, social services, dietary). Clients who most benefit from such conferences are those with multiple, complex problems. The emergency physician is no longer needed to address care provided in the health care facility.

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? A never event A variance A sentinel event An audit

A variance

HIPAA allows incidental disclosures of client health information as long as it cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of client health information. What are examples of this type of client health information disclosure? Select all that apply. The nurse leaves a detailed appointment reminder message on a client's voice mail. A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. The nurse calls out names in the waiting room, but does not disclose the reason for the client visit. The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. The nurse uses white boards on an unlimited basis. The nurse uses sign-in sheets that contain information about the reason for the client visit.

A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. The nurse calls out names in the waiting room, but does not disclose the reason for the client visit. The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. Examples of incidental disclosures of client health information that are allowed by HIPAA regulations include: a visitor hearing a confidential conversation when the nurses are in appropriate surroundings and using low voices; the use of x-ray light boards that can be seen by a passersby as long as the x-rays are not left unattended by the health care staff; the calling out of names in the waiting room when the reason for the client visit is not disclosed. The following are not allowed by HIPAA regulation: the nurse using a sign-in sheet that contains information about the reason for the visit; the use of white boards on an unlimited basis; the nurse leaving a detailed appointment reminder message on a client's voice mail. It is important that the nurse is aware of HIPAA regulations and common examples of incidental disclosures that are considered allowed in the nurse's work setting.

A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines? Yelling at staff members, dementia worse today, refused breakfast Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth Confused, belligerent, and uncooperative with care Inappropriate behavior during breakfast, screamed during the shower, smiled while kicking other clients

Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth Nursing documentation should focus on behaviors and avoid words such as better, normal, or worse. Using terms such as "inappropriate behavior" or "belligerent" is judgmental. The nurse should document only actual behaviors that the nurse witnesses.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? Asking the emergency department nurse for information on the family member Calling the client information desk to find out the room number of the family member Finding the emergency medical technicians who transported the family members and inquiring about the injuries Accessing the electronic health record of the family member to find out extent of injury

Calling the client information desk to find out the room number of the family member Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

Which note includes all elements of a SOAP note? Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

Which is the primary purpose of client records? Reimbursement Legal protection Performance improvement Communication

Communication Client records serve many purposes. The primary purpose of the client record is to help health care professionals from different disciplines (who interact with the client at different times) communicate with one another. Communication fosters continuity of care. The ANA states that the most important purpose of client records is "communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory and legislative, reimbursement, research, and quality activities."

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error? Contact the health care provider. Create an addendum with a correction. Immediately delete the incorrect documentation. Contact information technology (IT) staff to make the correction.

Create an addendum with a correction. If the nurse is using an EMR and the documentation cannot be changed, an addendum will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies. The health care provider does not need to be contacted to make a correction, but does need to be informed if this caused any direct harm or effects to the client.

Which are appropriate actions for protecting clients' identities? Select all that apply. Document all personnel who have accessed a client's record. Have conversations about clients in private places where they cannot be overheard. Place light boxes for examining X-rays with the client's name in private areas. Ensure that clients' names on charts are visible to the public. Orient computer screens toward the public view.

Document all personnel who have accessed a client's record. Have conversations about clients in private places where they cannot be overheard. Place light boxes for examining X-rays with the client's name in private areas. Documenting all personnel who have accessed a client's record, placing light boxes for examining X-rays with the client's name in private areas, and having conversations about clients take place in private where they cannot be overheard are useful strategies to limit casual access to the identity of clients and health informatics. Orienting computer screens toward the public view and visibly displaying clients' names on charts are incorrect, as these are breaches of client confidentiality.

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edematous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"? PIE Narrative FOCUS Exception

FOCUS The nurse used FOCUS charting, as it gives priority attention to the client's current or changed behavior. PIE charting occurs when the nurse records the client's progress under the headings of problem, intervention, and evaluation. Narrative charting content resembles a log or journal entry. Charting by exception is charting only abnormal assessment findings that deviate from a standard norm. Therefore, this nurse is not demonstrating PIE, narrative, or exception charting.

Which statement is not true regarding a medication administration record (MAR)? The MAR distinguishes between routine and "as needed" medications. If the client declines the dose, the nurse does not have to document this on the MAR. The MAR identifies routine times for medication administration. After using an electronic MAR, the nurse should log off.

If the client declines the dose, the nurse does not have to document this on the MAR.

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? Transfer report Incident report Nurse's shift report Telemedicine report

Incident report

The nurse receives a verbal prescription from a health care provider during an emergency situation. Which action(s) should be taken by the nurse? Select all that apply. Include V.O. with the health care provider's name on the prescription. Read back the prescription. Record the date and time of the prescription. Record the prescription on the pharmacy discrepancy sheet. Have the health care provider review and sign the prescription during the emergency.

Include V.O. with the health care provider's name on the prescription. Read back the prescription. Record the date and time of the prescription. When a verbal prescription is received during an emergency, the nurse should record the prescription in the medical record, read back the prescription, mark the date and time of the prescription, and record V.O. with the name of the health care provider who issued the provider. After the emergency of the situation has ended, the health care provider should review and sign the prescription. Pharmacy discrepancy sheets are used to record discrepancies in medication inventories, which could indicate diversion, or theft, of prescription medications.

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 documents assessments on separate forms. It records progress under problems, intervention, and evaluation. It provides and refers to a client's problem by a number. It provides quick access to abnormal findings.

It provides quick access to abnormal findings. Charting by exception (CBE) provides quick access to abnormal findings, as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

Which principle should guide the nurse's documentation of entries on the client's health care record? Correcting fluid is used rather than erasing errors. Nurses should not refer to the names of physicians. Precise measurements should be used rather than approximations. Documentation does not include photographs.

Precise measurements should be used rather than approximations. Precise measurements and times must be used whenever possible. It is appropriate to use the names of physicians and photographs can constitute documentation. Handwritten entries should be struck through with a single line and initialed, not covered with correcting fluid or erased.

A nurse documents the following data in the client 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? Source-oriented method Problem-oriented method Focus charting method PIE charting method

Problem-oriented method The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care. Progress notes clearly focus on client problems. Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically. PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). Focus charting method brings the focus of care back to the client and the client's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a client and client care.

A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply. R: The nurse gives recommendations for future care to the new nurse in charge. S: The nurse discusses the client's symptoms with the new nurse in charge. B: The nurse gives the background of the client by explaining the client history. S: The nurse handling the transfer describes the client situation to the new nurse. R: The nurse explains the rules of the new facility to the client. A: The nurse presents an assessment of the client to the new nurse.

R: The nurse gives recommendations for future care to the new nurse in charge. B: The nurse gives the background of the client by explaining the client history. S: The nurse handling the transfer describes the client situation to the new nurse. A: The nurse presents an assessment of the client to the new nurse. Examples of using the SBAR technique are numerous. The nurse handling the transfer describes the client situation to the new nurse. The nurse gives the background of the client by explaining the client history. The nurse presents an assessment of the client to the new nurse. The nurse gives recommendations for future care to the new nurse in charge. The nurse does not explain the rules of the new facility to the client as part of the SBAR technique. The nurse would discuss the client's symptoms with the new nurse in charge as part of the "B" background, not the "S" situation.

A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse best reflects the effectiveness of the pain medication? States pain is not relieved, talking with family on phone. Rates pain higher on pain scale, notified physician. Rates pain 8/10, states nauseated for last 30 minutes. Vital signs within normal limits, sleeping.

Rates pain 8/10, states nauseated for last 30 minutes.

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? Document the UAP's conversation. Remind the UAP about the client's right to privacy. Report the UAP to the nurse manager. Notify the client relations department about the breach of privacy.

Remind the UAP about the client's right to privacy. The nurse should first remind the UAP about the client's right to privacy. All other actions are appropriate, but do not immediately protect the client's privacy.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? Documentation Reporting Dialogue Verification

Reporting Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. .Some facilities may use encrypted (protected) software programs such as Share Point or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? SBAR PIE SOAP MAR

SBAR

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation? PIE charting Source-oriented Charting by exception Problem-oriented

Source-oriented

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? Objective data are what the client states about the problem. Subjective data should be included when documenting. Abnormal laboratory values are common items that are documented. The plan includes interventions, evaluation, and response.

Subjective data should be included when documenting. Subjective data should be included when using the SOAP format for documentation. Objective data are what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care provider's judgment of the situation, and abnormal lab values would be included in objective data.

Which organization audits charts regularly? National League for Nursing The Joint Commission Sigma Theta Tau International American Nurses Association

The Joint Commission The Joint Commission (TJC)audits client records regularly under specific guidelines that are announced annually and shared with each institution. TJC also encourages institutions to set up ongoing quality assurance programs. The National League for Nursing, American Nurses Association, and Sigma Theta Tau International are professional nursing organizations that provide services to nurses; they do not access client records. .

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? The client is receiving sufficient relief from pain medication, stating no pain in either knee. The client reports that on a scale of 0 to 10, the current pain is a 3. The client appears comfortable and is resting adequately and appears to not be in acute distress. The client appears to have a low tolerance for pain and frequently reports intense pain.

The client reports that on a scale of 0 to 10, the current pain is a 3.

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? The abdominal area Lung sounds Heart rate and rhythm The lower extremities

The lower extremities Peripheral vascular disease mostly affects the lower extremities. While the lung sounds, heart rate and rhythm, and abdominal assessment will be important, the focused assessment should be on the lower extremities.

While assisting a client with a delivery, a nurse takes a photo of the newborn and posts it on a social media website. What action may occur related to this privacy violation? The nurse could be fined or even go to jail for violating HIPAA. There will be no repercussions if the nurse takes the photo down from the social media page. The nurse could be fired but would not face criminal charges or jail time. No action will be taken as long as the parents don't find out.

The nurse could be fined or even go to jail for violating HIPAA.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process? The nurse sends or directs someone to take action in a specific nursing care problem. The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

The nurse meets with nurses or other health care professionals to discuss some aspect of client care. A nursing care conference is a meeting of nurses to discuss some aspect of a client's care.

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which information? Nursing documentation and plan of care The physician's assessment and treatment Results of laboratory and diagnostic studies Information from other members of the health care team

The physician's assessment and treatment The medical history, physical examination, and progress notes record the findings of physicians as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment. The laboratory results will be in a different section of the health record and not typically in the medical history and treatment plan. Nursing documentation will be in the nursing section. Information from the other members of the health care team is found in the progress notes.

Which is not a purpose of the client care record? To serve as a legal document To serve as a contract with the client To assist with care planning To facilitate reimbursement

To serve as a contract with the client Client care records are legal documents, communication tools, and assessment tools. They are used for care planning, quality assurance, reimbursement, research, and education. They in no manner reflect a contract between health care staff and the client. The only exception to this is at the point of admission when the client (or responsible party) signs an acknowledgement of expenses about to be incurred as health care insurance information is obtained.

A new graduate is working at a first job. Which statement is most important for the new nurse to follow? Only document changes in the client's status. Document lengthy entries using complete sentences. Use PIE charting, even if it is not the institution's charting method. Use abbreviations approved by the facility.

Use abbreviations approved by the facility.

A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy? Do not release any information to the insurance company. Use minimum disclosure policy to release the information. Refer the insurance agency directly to the client. Release the full medical record to expedite payment.

Use minimum disclosure policy to release the information. The nurse should use minimum disclosure policy to release the information, as per HIPAA regulations. It is inappropriate to not release any information to the insurance company, to refer the insurance agent directly to the client, and to release the full medical record to expedite payment.

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of: reporting. a consultation. a referral. conferring.

a referral.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: relevant data. important information. factual statement. interpretation of data.

interpretation of data. A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: ensuring that abbreviations are understandable to clients who may seek access to their health records. limiting abbreviations to those approved for use by the institution. using only those abbreviations that are defined in full at another location in the client's chart. using only abbreviations whose meaning is self-evident to an educated health professional.

limiting abbreviations to those approved for use by the institution. In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and: staff development. reimbursement. change of mechanisms. research.

reimbursement

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? subjectivity objectivity organization reimbursement

subjectivity Quoting what the client is saying helps in the documentation of subjective data. Objective data are assessment data that may be directly observed by the nurse such as blood pressure. Organization is the structure of the documentation and does not relate to subjective data. Reimbursement is a distractor that doesn't relate to assessment data.

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? concerned with feeling tired describes wound as itchy urine output 100 ml pain rating of 4 on a scale of 0-10

urine output 100 ml Objective data, such as the measurable urine output, are collected by the nurse. Subjective data, such as feeling pain, itchiness, or fatigue, are reported by the client.

A client's record can be more accurate if the nurse: uses point-of-care documentation. summarizes client care at the end of the shift. delegates charting appropriately. charts at least every 6 hours.

uses point-of-care documentation. Point-of-care documentation takes place as care occurs, thus enhancing accuracy. Today many facilities incorporate technology that is mobile and can be used immediately at the client's bedside for point-of-care documentation. The nurse should not delegate documentation, nor should it be left to the end of a shift. Documentation should be performed more than once every 6 hours.

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family." "All aspects of clinical practice are confidential and should not be discussed." "You may continue to post about a client, as long as you do not use the client's name." "Any information that can identify a person is considered a breach of client privacy."

"Any information that can identify a person is considered a breach of client privacy." Any information that can identify a person is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the facility and unit is disclosed in the post. Discussion of clinical practice can be helpful for learning purposes or seeking advice on care. No care should be discussed, even privately, with friends and family without first obtaining the client's permission.

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best? "Vital signs do not need to be recorded unless they are abnormal." "The UAP is able to log in and enter the information so all members of the health care team can see it." "The UAP logs in under my name and documents the vital signs." "The UAP will tell me what the vital signs are, and I will record them in the record so the health care provider can review them."

"The UAP is able to log in and enter the information so all members of the health care team can see it."

A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift? "The client had a good deal of anxiety last night and requested to be turned and repositioned frequently." "The client was very restless last night so you may need to call the health care provider today to get a prescription for the client's anxiety." "The unlicensed assistive personnel turned the client every 2 hours last night, but the client should continue to be repositioned during the day." "No medical issues overnight that require immediate attention."

"The client had a good deal of anxiety last night and requested to be turned and repositioned frequently." In inpatient settings, the handoff that occurs when a new shift starts is often referred to as the change-of-shift report. This ensures continuity of client care from one shift to the next, allowing the oncoming nurse to receive information regarding the client's status or plan of care. The handoff should include objective information regarding the status of the client such as mental status, pain issues, and care performed. Subjective information is also in the handoff. This includes statements regarding anxiety. Brief, undescriptive statements are not comprehensive enough and positioning of the client, while important, is not thorough enough. Statement regarding restlessness may be important and the provider may need to be contacted, but this is not the most effective way to communicate information needed in the hand-off.

Which statement by the nurse is the best example of an internal communication strategy the nurse should use to discuss the use of new equipment, client care problems, and change in policies? "You will demonstrate the use of the cardiac monitor on the nursing rounds." "We will discuss the new policies at the change-of-shift report." "We will be having a team conference to discuss concerns that clients' relatives have raised." "You will see the procedure for using the new equipment in the client assignments."

"We will be having a team conference to discuss concerns that clients' relatives have raised." Team conferences are effective communication strategies to discuss the relatives' concerns because this usually involves the multidisciplinary team and the relatives could be involved. Change-of-shift report is incorrect since this is only a summary of each client's condition and current status of care in a discussion between the personnel of the outgoing and incoming shifts. Client assignment identifies the clients for whom the staff person is responsible and describes their care and is therefore incorrect. Nursing rounds is incorrect since this strategy provides the staff the opportunity to observe and converse in the client's presence and boost the client's confidence.

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR? "Will you prescribe a complete blood count to check the white blood cell count and a culture?" "The client was admitted today with a urinary tract infection." "I am concerned that the client might be exhibiting sepsis." "The client's temperature has been 102°F (38.9°C) for the last 6 hours."

"Will you prescribe a complete blood count to check the white blood cell count and a culture?" SBAR is an acronym for Situation, Background, Assessment, Recommendation. Situation is what the nurse describes, the current situation. Background is the pertinent information regarding the current situation. Assessment is objective information that supports the situation. Recommendation is what the nurse recommends to the health care provider. In this case, the Recommendation is the nurse asking the provider to prescribe a complete blood count and culture. "I am concerned that the client might be exhibiting sepsis" is a situation statement. "The client's temperature has been 102°F (38.9°C) for the last 6 hours" is the assessment of the client supporting the situation. The client being admitted today with a urinary tract infection is Background.

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? One U of glucose 1 bottle of glucose 1U of glucose 1 Unit of glucose

1 Unit of glucose The nurse should write "1 Unit of glucose." The nurse cannot write "1 bottle" or "one U of glucose" because these are not the accepted standards. "1U" is an abbreviation that appears in the JCAHO "Do Not Use" list (see http://www.jcaho.com). It should be written as "1 Unit" instead of "1U" because "U" is sometimes misinterpreted as "zero" or "number 4" or "cc."

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given? 2130 1930 0930 930 p.m.

2130

Which pieces of information should the nurse treat as confidential and not disclose? Select all that apply. A client's Social Security number A client's address A deceased client's history for organ donation A client's diagnosis linked to a disease outbreak Information about a client's past health conditions

A client's Social Security number A client's address Information about a client's past health conditions Client information that is considered confidential includes client names and all identifiers, such as address, telephone and fax number, Social Security number, and any other personal information. It also includes the reason the client is sick or in the hospital, office, or clinic, the assessments and treatments the client receives, and information about past health conditions. Exceptions to confidentiality include disclosure of client information for the purpose of tracking and notification of disease outbreaks and information about a deceased person's organ donation.

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 is requesting pain medications, is grimacing, and is diaphoretic. Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. Client states expecting some pain, but it is more severe than anticipated. Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." In the SOAP format, "S" refers to subjective data, which are usually recorded as the client's statement or anything verbalized by the client. The statement about pain secondary to postoperative status and increased activity reflect the "A," or assessment, portion of the SOAP format. The statements about the abdomen being soft, bowel sounds, and so on reflect the "O," or objective data, portion of the SOAP format. The statement about physical manifestations of pain is not subjective data.

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? Psychomotor skills Documentation Accreditation Clinical judgment

Documentation Documentation is the primary source of evidence used to measure performance outcomes, according to the CNA. Accreditation is the process whereby educational institutions are evaluated and, if approved, certified by a third party to validate their competency. Psychomotor skills are skills that require physical actions and muscular coordination to perform. Clinical judgment is an attribute of health care professionals that involves the use of critical thinking, intuition, and clinical experience when making a decision about a client's care to achieve the best outcome for the client.

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legally defensible charting? Leave spaces between entries and signature. Ensure that the client's name appears on all pages. Record all facts and subjective interpretations. Use abbreviations wherever possible.

Ensure that the client's name appears on all pages. The nurse should ensure that the client's name appears on all pages to ensure legally defensible charting. The nurse should not leave spaces between entries and signature so that the document is legally acceptable. The nurse should use only abbreviations approved by the facility, and should not use abbreviations wherever possible. The nurse should record all the facts, but not any subjective interpretations, to ensure that the document is legal evidence.

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate? Mediate a meeting between the parent and client. Explain the reason why information cannot be disclosed. Verify the insurance coverage before giving information. Refer the parent to the health care provider providing care.

Explain the reason why information cannot be disclosed. The nurse needs to explain the reason why information cannot be released to the parents. Providing insurance coverage does not negate the privacy laws. Referring the parent to the health care provider is inappropriate since the health care provider cannot release the information either. Mediating a meeting between the parent and client would only be appropriate if the client requested the meeting.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? Add the new order to the medication administration record. Write the order in the client's record. Call the pharmacy to have the order entered in the electronic record. Inform the health care provider that a written order is needed.

Inform the health care provider that a written order is needed. Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.

The nurse is calling a health care provider to give an update on a client's condition. The nurse receives a telephone order and, when requests that the order be read back to the provider for confirmation, the provider states, "I don't have time for this." What is the most appropriate action by the nurse? Ask the secretary to call the provider back and take the order Don't follow through with the order, and delete it from the record Proceed with the order since the nurse heard it the first time Inform the provider, to ensure safety for the client, it must be read back

Inform the provider, to ensure safety for the client, it must be read back

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 Making the names of clients on charts visible to the public Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Posting information linking a client with diagnosis, treatment, and procedure on whiteboards Keeping record of people who have access to clients' records

Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records Obscuring identifiable names of clients and private information about clients on clipboards; placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public; and keeping record of people who have access to clients' records are required under the Health Insurance Portability and Accountability Act (HIPAA), which is legislation that attempts to limit casual access to the identity of clients. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards and making the names of clients on charts visible to the public are violations of HIPAA, as these activities allow casual access to the identity of clients.

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. Problem-oriented recording gives clients the right to withhold the release of their information to anyone. Problem-oriented recording has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers.

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

In SBAR, what does R stand for? Reinforcing data Report Recommendations Response

Recommendations

When the home care nurse visits a client, who is recently widowed, the nurse finds that the home is cluttered with trash. The client appears sad and disheveled. Which action would the nurse take based on the assessment findings? Move the client to an assisted living facility. Clean up the house. Call the health department. Refer to the health care provider.

Refer to the health care provider. Symptoms of depression include poor cognitive performance, sleep problems, and lack of initiative. The nurse would refer the client to a health care provider for treatment of depression. Calling the health department or cleaning up the house will not help with the client's depression. Moving the client to an assisted living facility may not be necessary if the client receives treatment for the depression.

The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? Access the health care record at the bedside and show the client how to navigate the electronic health record. Review the hospital's process for allowing clients to view their health care records. Explain that only a paper copy of the health care record can be viewed by the client. Discuss how the hospital can be fined for allowing clients to view their health care records.

Review the hospital's process for allowing clients to view their health care records. The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the records.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing? narrative charting PIE charting FOCUS charting SOAP charting

SOAP charting The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? Disclosing client health information for research purposes after obtaining permission from the client's physician Submitting a written notice to all clients identifying the uses and disclosures of their health information Releasing the client's entire health record when only portions of the information are needed Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information

Submitting a written notice to all clients identifying the uses and disclosures of their health information Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the physician's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations.

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? The provider can input orders remotely into the EHR system for the nurse to retrieve. The client must be stabilized before the nurse can obtain any orders from the provider. The nurse can implement care once written orders are received from the provider. The nurse can accept verbal orders to provide immediate care and record once the client is stable.

The nurse can accept verbal orders to provide immediate care and record once the client is stable. In most agencies, the only circumstance in which the attending physician, nurse practitioner, or house office may issue orders verbally is in a medical emergency. In such a situation, the physician/nurse practitioner is present but finds it impossible to write the order due to the emergency circumstances. When a client is admitted to the unit, the prescriber writes orders either in the electronic record or on paper. Physicians/providers can insert orders remotely, but this is not the most appropriate option in an emergency. Stabilization of the client, while important, should not supersede receiving orders as the providers instructions could be integral to stabilizing the client.

Which example may illustrate a breach of confidentiality and security of client information? The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. The nurse provides information to a professional caregiver involved in the care of the client. The nurse provides information over the phone to the client's family member who lives in a neighboring state. The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell.

The nurse provides information over the phone to the client's family member who lives in a neighboring state. Providing information over the phone to a family member without knowing whether or not the client wants that family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach of confidentiality, but providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.

Which documentation by the nurse best supports the PIE charting system? States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given Vomiting 250 mL undigested food, antiemetic given, no further vomiting Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg

Vomiting 250 mL undigested food, antiemetic given, no further vomiting PIE charting includes the problem, intervention, and evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (problem), antiemetic given (intervention), no further vomiting (evaluation).

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? Place the narrative note chronologically after the respiratory therapist's note. Write a narrative note in the designated nursing section. Review the laboratory results under the physician section. Use a critical pathway to document the physical assessment.

Write a narrative note in the designated nursing section. Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the physician section. Critical pathways are not used to document physical assessments.

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 client who is not making progress in expected outcomes of care a client whose rehabilitation potential is not good a client whose status is stabilized

a client who is homebound and needs skilled nursing care Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation? focus charting by exception narrative SOAP

charting by exception

What ensures continuity of care? integration critical thinking reassessment communication

communication