Chapter 10

The federally initiated goal of computer-based personal records would likely produce which of the following benefits? *Select all that apply.* A) Access to records outside of the client's home facility B) Increased accuracy of treatment for the client outside their home facility C) Easier access to data for research D) Increased incidence of identity theft E) Greater accuracy and improved client care

A) Access to records outside of the client's home facility B) Increased accuracy of treatment for the client outside their home facility C) Easier access to data for research E) Greater accuracy and improved client care *Rationale* An increase in identity theft would not be considered a benefit of computer-based personal records.

The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which information should the nurse record in his or her charting? *Select all that apply.* A) Client is crying. B) Client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today." C) Client seems depressed. D) Client is suicidal. E) Client is in a bad mood.

A) Client is crying. B) Client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today." *Rationale* When documenting observations of client behavior, the nurse must maintain objectivity by describing the actual behaviors, rather than attempting to interpret the behaviors. For example, the nurse should not describe the client as depressed, suicidal, or in a bad mood.

The client record is utilized for many purposes. Which might be a use for the client record? *Select all that apply.* A) Education of student nurses B) Reimbursement for services C) Research D) Giving information over the phone when unidentified callers call the hospital unit E) Education for medical students

A) Education of student nurses B) Reimbursement for services C) Research E) Education for medical students *Rationale* The client medical record may be used for education, reimbursement, and research. The record is never used to give information to callers without written authorization from the client.

How can a nurse obtain additional information about a client? A) Read the client's history and assessment. B) Call the client's family. C) Ask the client's sister about the family history. D) Review nursing literature.

A) Read the client's history and assessment. *Rationale* Nurses and other team members gather assessment data from the client record. By reading about the client's history and initial assessment, and comparing these data with additional subjective and objective information that has been obtained, current health status and progress toward goals can be determined.

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

A) The Joint Commission *Rationale* The Joint Commission audits client records regularly and encourages institutions to set up ongoing quality assurance programs.

Which entry should the nurse include when charting? *Select all that apply.* A) The nursing assistant reports the client's breath smelled of alcohol. B) I feel something is going on he or she is not telling me. C) The client was overheard telling his or her family about more bleeding than he or she has reported to his or her physician. D) The incision is oozing a small amount of red blood. E) The client's pupils are dilated.

A) The nursing assistant reports the client's breath smelled of alcohol. C) The client was overheard telling his or her family about more bleeding than he or she has reported to his or her physician. D) The incision is oozing a small amount of red blood. E) The client's pupils are dilated. *Rationale* Entries must be accurate. Nurses must chart only observations that they have seen, heard, smelled, or felt. An observation made by another health professional must be clearly identified as such.

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

A) Use abbreviations approved by the facility. *Rationale* Use abbreviations, but only those that are commonly accepted and approved by the facility.

When a nurse recognizes having documented one client's assessment data on the wrong client's medical record, the nurse should: A) draw a single line through the error, and initial it. B) use a felt tip pen to cover the error. C) use white out to cover the error. D) replace the record, rewriting the error.

A) draw a single line through the error, and initial it. *Rationale* When an error occurs, the nurse should draw a single line through the error and place his or her initials above it.

A nurse is working as a case manager, and in this role, he or she audits charts. Audits of client records are performed primarily for quality assurance and: A) reimbursement. B) staff development. C) research. D) change of mechanisms.

A) reimbursement. *Rationale* Audits of client records serve a dual purpose: quality assurance and reimbursement.

Which of the following flow sheets provides the reader with information on an ongoing record of fluid loss? A) Vital sign sheet B) Intake and output sheet C) Critical care flow sheet D) Health assessment flow sheet

B) Intake and output sheet *Rationale* The intake and output sheet is used to maintain an ongoing record of all fluid intake and output.

A concise document that provides most of the client's nursing and medical information is a(n): A) nursing care plan. B) Kardex. C) past chart. D) office record.

B) Kardex. *Rationale* The Kardex is a way to ensure continuity of care from one shift to another and from one day to the next.

Besides being an instrument of continuous client care, the client's medical record also serves as a(an): A) assessment tool. B) legal document. C) Kardex. D) incident report.

B) legal document. *Rationale* The client record serves as a legal document of the client's health status and care received.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining: A) subjectivity. B) objectivity. C) organization. D) reimbursement.

B) objectivity. *Rationale* Directly quoting statements made by the client can help in maintaining objectivity.

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

B) uses point-of-care documentation. *Rationale* Point-of-care documentation takes place as care occurs, thus enhancing accuracy. Documentation is not normally delegated and should not be left to the end of a shift. It should be performed more than once every 6 hours.

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in his or her charting? A) "If I make an error, I can draw a red circle around it." B) "If I make an error, I have to rewrite the entire entry." C) "If I make an error, I draw a single line through it and put my initials by it." D) "If I make an error, I place an X through it." E) "If I make an error, I use white-out on it."

C) "If I make an error, I draw a single line through it and put my initials by it." *Rationale* When an error occurs, the nurse should draw a single line through the error and place his or her initials above it.

The client states, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today." The client's arms are folded across the chest. The brow is furrowed and the client refuses to allow morning vital sign measurements. Which entry should be included in the nurse's charting? *Select all that apply.* A) Seems angry today. B) Unhappy with his or her care. C) Arms are folded across his or her chest and brow is furrowed. D) States, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today." E) Refuses to allow morning vital sign measurements.

C) Arms are folded across his or her chest and brow is furrowed. D) States, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today." E) Refuses to allow morning vital sign measurements. *Rationale* When documenting observations of client behavior, the nurse must maintain objectivity by describing the actual behaviors, rather than attempting to interpret the behaviors. The nurse should not describe the client as angry or unhappy.

What ensures continuity of care? A) Reassessment B) Critical thinking C) Communication D) Integration

C) Communication *Rationale* Communication ensures continuity of care and provides essential data for revision or continuation of care.

A nurse in a nursing home is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent? A) PIE note B) Flow sheet C) Narrative note D) SOAP note

C) Narrative note *Rationale* A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, client activity pattern, and comfort measures provided, along with the client's response.

The nurse is caring for a client with uncontrolled hypertension. His or her blood pressure has remained controlled for the nurse's shift. At 2-hour intervals, the blood pressure was checked by the nurse and found to be essentially the same. The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the client has a stroke. Years later, the client files a lawsuit blaming the hospital for the stroke. The nurse who was caring for the client when the client's blood pressure was stable cannot recall the exact blood pressure readings obtained, but remembers it was normal. Will this recollection suffice in court and why? A) Yes, the nurse remembers the pressure as normal during his or her shift and can swear to it during the deposition. B) No, but it will relieve the nurse of any wrongdoing. C) No, if the blood pressure measurement was not documented, it did not happen. D) Yes, the nurse was not on duty when the stroke occurred.

C) No, if the blood pressure measurement was not documented, it did not happen. *Rationale* Legal cases have been argued with the principle that "If it was not documented, it was not done." For this reason, it is important to document normal as well as abnormal findings. Because nurses and other healthcare team members cannot remember specific assessments or interventions involving a client years after the fact, accurate and complete documentation at the time of care is essential.

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

C) Precise measurements should be used rather than approximations. *Rationale* 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, not covered with correcting fluid or erased.

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

C) Reporting *Rationale* Reporting takes place when two or more people communicate information about client care, either face to face, or by recording, computer charting, or telephone. Dialogue is two-way communication, which is not always the case for reporting.

Which statement describes best practices for charting? *Select all that apply.* A) Use long narratives to be sure your documentation is understood. B) Always use complete sentences. C) Use only approved abbreviations. D) Always use the client's name and words referring to the client in each entry. E) Use partial sentences and phrases.

C) Use only approved abbreviations. E) Use partial sentences and phrases. *Rationale* Good charting is concise and brief. In narratives, use partial sentences and phrases; drop the client's name and terms, referring to the client. Use abbreviations but only those that are commonly accepted and approved by your facility.

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic client chart is: A) no other charting method is necessary. B) access is open to anyone. C) retrieval of information is more efficient. D) it is less costly to maintain.

C) retrieval of information is more efficient. *Rationale* With the advance of computer technology, many institutions are transforming the client record to electronic format. Multiple people may access portions of the record from different sites at the same time.

What dual purpose does an audit serve? A) Communication and evaluation B) Knowledge and quality C) Education and confidentiality D) Quality assurance and reimbursement

D) Quality assurance and reimbursement *Rationale* Audits of client records serve a dual purpose: quality assurance and reimbursement.

During a client's hospitalization, the client has developed shortness of breath, with edema. What action should the nurse take? A) Review the nursing care plan. B) Implement changes in the current interventions. C) Involve the family in changes. D) Revise the plan of care.

D) Revise the plan of care. *Rationale* A plan of care should be generated at admission and revised to reflect changes in the client's condition.

Charting in which the nurse writes a progress note that relates to one health problem is a: A) PIE note. B) Flow sheet. C) Narrative note. D) SOAP note.

D) SOAP note. *Rationale* SOAP note is a progress note that relates to only one health problem.

How can the nurse researcher obtain information from a client record? A) Audit discharge records B) Interview nursing staff C) Examine institutional procedures D) Study client records

D) Study client records *Rationale* Nursing and healthcare research is often carried out by studying client records.

Which characteristic of a nurse's charting will assist most in the avoidance of errors? A) Detail B) Brevity C) Subjectivity D) Timeliness

D) Timeliness *Rationale* Documentation in a timely manner can help avoid errors. Accuracy is prioritized over brevity and subjectivity is not a goal of documentation. It is necessary to provide sufficient detail, but this will not necessarily avoid errors.