Chapter 19: Documenting and Reporting
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?
Refer to the health care provider. Explanation: 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 charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?
Subjective data should be included when documenting. Explanation: 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.
The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?
The client reports waking up this morning with a severe headache. Explanation: The statement uses approved abbreviations for complains of (c/o) and headache (H/A). Therefore the statement indicates that the client is complaining of a severe headache this morning. The abbreviation c/o stands for complains of, not coughing. The abbreviation H/A stands for headache, not heart attack or heartburn.
A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate?
Write a narrative note in the designated nursing section. Explanation: 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 maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?
progress notes Explanation: In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.
Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing?
Nutritional consult Explanation: A nutritional consult would be most appropriate for this situation. Social services, a pulmonologist, or a podiatrist would not be effective to improve the client outcomes.
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:
a referral. Explanation: Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.
Which statement is not true regarding a medication administration record (MAR)?
If the client declines the dose, the nurse does not have to document this on the MAR. Explanation: If a client declines a dose, the nurse should circle that dose and write a note as to why the nurse did not administer it. MARs can distinguish between routine and "as needed" medications identify routine times for medication administration. After using an electronic MAR, the nurse should log off to prevent others from inadvertently adding information about other clients to the initial client's record.
A client is scheduled for a CABG procedure. What information should the nurse provide to the client?
"A coronary artery bypass graft will benefit your heart." Explanation: Coronary artery bypass graft is abbreviated CABG. It does not identify nutritional needs, decrease liver inflammation, or increase intestinal motility.
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 allow for us to see the client and possibly increase client participation in care." Explanation: 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.
A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?
Graphic sheets Explanation: The graphic record 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. Flow sheets are documentation tools used to efficiently record routine aspects of nursing care, not data as asked in the question. The purpose of progress notes is to inform caregivers of the progress a client is making toward achieving expected outcomes. The medical record is a general term for all of the client's medical information, which would include progress notes, flow sheet, and graphic sheets, to name a few.
The health care provider tells the client, "You are experiencing an MI," and leaves the room. The client asks the nurse what an MI stands for. What response by the nurse is most accurate?
"Myocardial infarction." Explanation: The common abbreviation for myocardial infarction is MI.
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." Explanation: 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.
A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?
"According to HIPAA legislation, you have a right to request changes to inaccurate information." Explanation: The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records. They may also update their health record if inaccurate, get a list of the disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations, request a restriction on certain uses or disclosures, and choose how to receive health information.
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?
"Any information that can identify a person is considered a breach of client privacy." Explanation: 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.
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 think the client would benefit from intravenous furosemide." Explanation: 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 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." Explanation: Clients have the right to see their own medical records and request changes to documentation that may be in error. Most facilities have a policy in place for the client to obtain medical records and the nurse should ensure that the policy is followed by being familiar with that policy prior to giving the client free access to the record. The nurse should not demean the client by assuming that the information may be confusing. The nurse should not allow the client access to the computer while using the nurse's password or login information. While the hospital maintains responsibility for the record, the client has the right to see it.
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." Explanation: The client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. The other answers are therefore inappropriate responses.
A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information?
1 Unit of glucose Explanation: 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."
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 variance Explanation: This scenario reflects a variance in care. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client.
The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states:
Although not written, the nurse must know or question the rationale before performing an action. Explanation: Although the scientific rationale is not documented in the clinical plan, it is no less important than in the instructional plan. Nurses and other members of the healthcare team must know the rationale behind the intervention or must question and review the rationale before performing the action.
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?
Create an addendum with a correction. Explanation: 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.
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 provides quick access to abnormal findings. Explanation: 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.
The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?
Reporting Explanation: 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 in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply.
Showing the provider the trends from baseline to present in blood pressure Informing the provider of the client's present heart rate of 116 beats/min Faxing the results of blood chemistry levels to the provider's office Explanation: Reporting to the primary care provider can occur face-to-face, by telephone, by text messaging, or, in some settings (e.g., long-term or home care), by fax. Placing a note on a computer terminal with client information or writing the hemoccult results on a piece of paper and leaving it at the desk is a violation of the Health Insurance Portability and Accountability Act because the information is visible and accessible to anyone passing by. The other answers are appropriate ways to communicate client information to a health care provider while protecting the client's confidentiality.
Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?
Submitting a written notice to all clients identifying the uses and disclosures of their health information Explanation: 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.
A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment?
The lower extremities Explanation: 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.
Which is not a purpose of the client care record?
To serve as a contract with the client Explanation: 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.
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:
interpretation of data. Explanation: 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.
The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?
subjectivity Explanation: 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.
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 Explanation: 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 nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?
"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." Explanation: SBAR refers to: S (situation): what is the situation you are calling about?; B (background): pertinent background information related to the situation; A (assessment): what is your assessment of the situation?; R (recommendation): explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.
Which note includes all elements of a SOAP note?
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. Explanation: A SOAP note consists of subjective information, objective information, an assessment, and a plan. The correct response includes each of these while the remaining three responses are each lacking a different one of the components.
Which principle should guide the nurse's documentation of entries on the client's health care record?
Precise measurements should be used rather than approximations. Explanation: 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.
The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which information?
The physician's assessment and treatment Explanation: 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.
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 meets with nurses or other health care professionals to discuss some aspect of client care. Explanation: A nursing care conference is a meeting of nurses to discuss some aspect of a client's care.
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?
"I will arrange access for you to review the record after you put your request in writing." Explanation: 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.
Which is the proper way to document midnight in a client's record?
0000 Explanation: 0000 is the military time for midnight and is correct. The other military times are incorrect since 2401 is 1 minute past midnight, 1200 is noon, and 1201 is 1 minute past noon.
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 states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." Explanation: 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.
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. Explanation: Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers is an advantage of problem-oriented recording and is therefore correct. Giving clients the right to withhold the release of their information to anyone is a beneficial disclosure and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving clients' problems among caregivers and having 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 are examples of source-oriented recording.
In SBAR, what does R stand for?
Recommendations Explanation: SBAR stands for situation, background, assessment, and recommendations. The other responses are incorrect.
Which information should the nurse include in a client's plan of care? Select all that apply.
The client's problems, goals, and nursing orders Routine care, such as the client's bath and mouth care The client's level of activity and current medical orders Explanation: The nurse should include the client's problems, goals, and nursing orders; routine care; level of activity; and current medical orders in the client's plan of care, as this information contributes to the nursing care plan. The nurse should not include client care assignment of the nursing and support staff in the client's care plan, as this information is not specific to one client. The nurse should not include minutes from the team conference meetings, as team conferences involve discussing client care problems among selected staff members.
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 Explanation: 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.
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." Explanation: The clients' medical records are good sources of data for research and education, and, therefore, it is incorrect to say that they are an obstruction. The other statements do not need correction.
Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?
A client has asked a nurse if he can read the documentation that his physician wrote in his chart. Explanation: Among the provisions of HIPAA are clients' rights to see and read their medical records. Negotiation with an insurance provider, the necessity of a second opinion, and out-of-state care are aspects of care that fall within the specific auspices of HIPAA.
Which are appropriate actions for protecting clients' identities? Select all that apply.
Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard. Explanation: 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 patient confidentiality.
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?
Remind the UAP about the client's right to privacy. Explanation: 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 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 reports that on a scale of 0 to 10, the current pain is a 3. Explanation: The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.
Which finding from a nursing audit reflects high standards for client safety and institutional health care?
The nurse documents clients' responses to nursing interventions. Explanation: Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by The Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health histories and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation.
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?" Explanation: 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 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. Explanation: When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times.
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:
limiting abbreviations to those approved for use by the institution. Explanation: 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 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?
Problem-oriented method Explanation: 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.
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?
Review the hospital's process for allowing clients to view their health care records. Explanation: 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.
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 Explanation: An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.
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 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 Explanation: 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.
With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.
any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders Explanation: Any identifying information regarding the client's demographics such as name, age, gender, diagnosis, and so on should be communicated to the oncoming nurse caring for the client. Any current orders or orders that have not been completed during the shift should be communicated as well. The oncoming nurse should be informed of any occurrences with the client that have been out of the norm and what actions, if any, were taken. Information about what the client watched for entertainment is not of relevance and should be eliminated from the report, as well as what time the nurse will be working next.
A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?
identifying risks and ensuring future safety for clients Explanation: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team.
