Chapter 16: Documenting, Reporting, Conferring, and Using Informatics

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

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

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

A flow sheet A flow sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special needs.

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?

Accurately documenting client care on the client record

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?

Calling the client information desk to find out the room number of the family member

Which statement is not true regarding a medication administration record (MAR)?

If the client refuses the dose you don't 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?

Incident report

Which abbreviation is correct for use in documentation?

PO

Which organization audits charts regularly?

The Joint Commission

A client has been diagnosed with PVD (peripheral Vascular Disease). What area of the body should the nurse focus the assessment?

The lower extremities

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data.

A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis?

public health department

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit." HIPAA has created several changes that protect client confidentiality and affect the workplace. One such change is that the names of clients on charts can no longer be visible to the public, and clipboards must obscure identifiable names of clients and private information about them. Therefore, writing down clinical information, taking the data off the unit, and including client identifiers are inappropriate statements.