Chapter 19: Documenting and Reporting

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

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

subjectivity

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."

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."

The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development?

"The care plan is required for every client by The Joint Commission."

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.

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.

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

Reporting

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?

SOAP charting

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.

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

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document.

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."

A new graduate is working at a first job. Which statement is most important for the new nurse to follow?

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. Explanation: 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 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

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."

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them.

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

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."

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

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?

Inform the health care provider that a written order is needed.

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.

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.

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.

Which is true of collaborative pathways?

Are also called critical pathways or care maps

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

Client's record and occurrence report Explanation: 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.

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? -Call the health department. -Clean up the house. -Move the client to an assisted living facility. -Refer to the health care provider.

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.

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

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.

Which statement about client records and documentation is correct? -Communication is the primary purpose of client records. -Clients should keep the original record at home in a fireproof safe. -Nurses should not document progress notes in a client's record. -Physicians will not review nurses' documentation in the client's record.

Communication is the primary purpose of client records. Explanations: Communication is the primary purpose of client records. Original records are kept by the facility, not the client. Nurses should document key information in the client record, and physicians review nursing documentation to help make clinical decisions.

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.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?

those directly involved in the client's care

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." -"You may continue to post about a client, as long as you do not use the client's name." -"All aspects of clinical practice are confidential and should not be discussed." -"The information being posted on social media is inappropriate. -"Make sure to discuss information about clients privately with friends and family."

"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.

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 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, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. -The nurse sends or directs someone to take action in a specific nursing care problem.

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.

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. Does the nurse know what is important when working with a client translator? -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.

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.

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate? -Ask the client if information can be given to the parent. -Provide the information to the parent. -Explain the reasons for the hospitalization, but give no further information. -Take the parent to the client's room and have the client give the requested information.

Ask the client if information can be given to the parent.' Explanation: No information should be provided by the nurse without permission from the client. Taking the parents to the client's room to get information from the client may violate the client's privacy.

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 -The client care assignment of the nursing and support staff -The minutes of the most current team conference meetings

-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 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." -"It seems like this client has fluid volume overload." -"I think the client would benefit from intravenous furosemide."

"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 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." -"The provider will need to give permission for you to review." -"I am sorry I can't access that information."

"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.

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 provide data for legal evidence." -"I can share the clients' medical records with the health care team." -"The clients' medical records are an obstruction to research and education." -"The clients' health records should be used to promote reimbursement from insurance companies"

"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.

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 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? -"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." -"The client was admitted today with a urinary tract infection." -"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

"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 nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them.

-"I don't feel well. I've been urinating often, and it burns when I urinate." -Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. -Fever, possible urinary tract infection -Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. Explanation: When using the SOAP format, the nurse would first document the subjective data (S: the client's complaint), objective data (O: abdomen, urine characteristics, temperature and contributing factors), assessment (A: caregiver's judgment about the situation—fever and possible urinary tract infection), and plan (P: what the caregiver is going to do—notify the physician, encourage fluids, and continue to monitor).

Which are appropriate actions for protecting clients' identities? Select all that apply.

-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. -Document all personnel who have accessed a client's record.

A client will be transferred from the cardiovascular intensive care unit to the telemetry unit for continued care. Which documentation correctly demonstrates how the nurse would prepare information to be conveyed to the receiving nurse during a verbal handoff report? -Mr. Alfred Jones, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes. -MR#12345, Alfred Jones, 76-year-old male 8 days post-op for RVEF. Transferring for monitoring for the next week. Braden score 13 and vitals are stable. IV fluids are currently being administered through R wrist with D51/2 NS + 20 mEq KCl at 125 ml/hr with orders to continue for 3 days. Pain at incision rated at 4 on a scale of 0-10 relieved with a combination of oxycodone and acetaminophen at 0845 with relief within 30 minutes. -Mr. Alfred Jones, 8 days post-CABG to correct RVEF is being transferred to the telemetry unit. Vitals are BP 130/82, P 82 and irregular, R 21, T 99.2F (37.3C). Client is currently receiving D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Oxycodone pain medication administered at 0800 along with PRN acetaminophen. -Alfred Jones, 76-year-old male-Transferring for monitoring for the next 7 days. Vitals are stable. IV fluids are currently being administered through R wrist with D51/2 NS + 20 mEq KCl at 125 ml/hr. Pain at incision relieved with a combination of oxycodone and acetaminophen at 0845.

-Mr. Alfred Jones, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes. Explanation: The nurse should include the current assessment of the client in the verbal handoff summary because it enables the receiving nurse to prepare for the client before arrival. It also allows the receiving nurse to clarify any information that may appear on the written handoff form. Additionally, the nurse should also report the presence of any intravenous fluids and the presence of advanced directives. It is not important to mention the client's medical record number during the communication. Information about intake for the previous meal would only be important if these were directly influencing the client's current status.

Which actions should the nurse take before making an entry in a client's record? Select all that apply. -Reviewing the agency's list of approved abbreviations -Choosing the charting format that the nurse prefers -Locating clients' files within an electronic health record system -Identifying the form appropriate to be used for documenting -Checking that clients' names are not identified within the chart forms

-Reviewing the agency's list of approved abbreviations -Locating clients' files within an electronic health record system -Identifying the form appropriate to be used for documenting Explanation: The nurse should review the agency's list of approved abbreviations, as each agency may use a different set of approved abbreviations and has approved its use for legally defensible reasons. The nurse should locate clients' files within an electronic health record system rather than creating a new record, to avoid duplication and missing important information in the client's record that was added previously. The nurse should identify the form appropriate to use for documenting, because some aspects of clients' care are recorded on specific forms. The nurse should use the charting format required by the facility, not choose one that the nurse prefers. The client's name should be identified on chart forms, so that if the forms become separated from the chart, the nurse will still be able to identify which client chart they belong to.

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. -S: The nurse handling the transfer describes the client situation to the new nurse. -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. -A: The nurse presents an assessment of the client to the new nurse. -R: The nurse explains the rules of the new facility to the client. -R: The nurse gives recommendations for future care to the new nurse in charge.

-S: The nurse handling the transfer describes the client situation to the new nurse. -B: The nurse gives the background of the client by explaining the client history. -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 Explanation: 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.

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 a provider? -The nurse can accept verbal orders to provide immediate care and record once the client is stable. -The provider can input orders remotely into the EHR system for the nurse to retrieve. -The nurse can implement care once written orders are received from the provider. -The client must be stabilized before the nurse can obtain any orders from the provider.

-The nurse can accept verbal orders to provide immediate care and record once the client is stable. Explanation: 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 are purposes of documentation in health care records? Select all that apply. -To facilitate quality -To serve as a financial record -To support decision analysis -To assist with clinical research -To provide personal communication to the family

-To facilitate quality -To serve as a financial record -To support decision analysis -To assist with clinical research Explanation: Documentation provides data to facilitate quality, serve as a financial record, assist with clinical research, and support decision analysis. Documentation does not serve to provide personal communication to the family.

A nurse is working as part of a team that has been asked to address the issue of confidentiality and documentation of client health information electronically. Which activity(ies) would the team suggest to help ensure confidentiality? Select all that apply. -having each person responsible for documenting in the electronic health record not share his or her password -placing computer screens in locations that face away from any public areas such as hallways -ensuring that individuals log off a computer terminal when documentation is completed -promoting the sharing of printers among several units -allowing confidential emails to be sent via a public network

-having each person responsible for documenting in the electronic health record not share his or her password -placing computer screens in locations that face away from any public areas such as hallways -ensuring that individuals log off a computer terminal when documentation is completed Explanation: To ensure confidentiality of client information, individual users should not share or expose passwords and should log off a terminal when documentation is completed. Screens should be turned away from public areas, and units should have separate printers, not printers that are shared by several units. Confidential emails should not be sent via public networks.

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 -An audit -A sentinel event

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.

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation? -Fill out an incident report. -Attach a copy of the incident report to the chart. -Stop the infusion and document the time. -Report the error to the primary provider.

Attach a copy of the incident report to the chart. Explanation: For legal reasons, the nurse should not attach a copy of the incident report to the chart. The nurse should, however, stop the infusion and document the time, report the error to the primary provider and nursing supervisor, and fill out an incident report.

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? -Immediately delete the incorrect documentation. -Create an addendum with a correction. -Contact information technology (IT) staff to make the correction. -Contact the health care provider.

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.

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? -Inform the health care provider that a written order is needed. -Write the order in the client's record. -Call the pharmacy to have the order entered in the electronic record. -Add the new order to the medication administration record.

Inform the health care provider that a written order is needed. Explanation: 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.

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

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions

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. -Documentation does not include photographs. -Precise measurements should be used rather than approximations. -Nurses should not refer to the names of physicians.

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.

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 -PIE charting method -Problem-oriented method -Focus 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. -Access the health care record at the bedside and show the client how to navigate the electronic health record. -Discuss how the hospital can be fined 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.

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.

During hospitalization, the client has developed shortness of breath with edema. What action should the nurse take? -Review the nursing care plan. -Implement changes in the current interventions. -Involve the family in changes. -Revise the plan of care.

Revise the plan of care. Explanation: A plan of care should be generated at admission and reviewed regularly. The care plan must be revised to reflect changes in the client's condition. Changes in the care plan will then reflect new interventions to address those changes. The family will not be directly involved in any changes in nursing care.

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? -Source-oriented -Problem-oriented -PIE charting -Charting by exception

Source-oriented Explanation: A source-oriented record 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, with the most recent entry being nearest the front of the record. Problem-oriented medical record (POMR) or problem-oriented record is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. PIE charting system is unique in that it does not develop a separate care plan. The care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified). In this documentation system, a client assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms (flow sheets). Client problems identified in these assessments are numbered, documented in the progress notes, worked up using the problem, intervention, evaluation (PIE) format, and evaluated each shift. Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes.

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 -Releasing the client's entire health record when only portions of the information are needed -Submitting a written notice to all clients identifying the uses and disclosures of their health information -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 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.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

Which example may illustrate a breach of confidentiality and security of client information? -The nurse provides information over the phone to the client's family member who lives in a neighboring state. -The nurse provides information to a professional caregiver involved in the care of the client. -The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. -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. Explanation: 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.

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 -Results of laboratory and diagnostic studies -Nursing documentation and plan of care -Information from other members of the health care team

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.

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

Vomiting 250 mL undigested food, antiemetic given, no further vomiting Explanation: 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? -Write a narrative note in the designated nursing section. -Place the narrative note chronologically after the respiratory therapist's note. -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. 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.

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? -SOAP -narrative -focus -charting by exception

charting by exception Explanation: Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. In the scenario, the BP is abnormal and is documented by exception. The other types of documentation are not being represented in this scenario.

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest? -charting by exception -narrative notes -problem, intervention, and evaluation note -FOCUS data, action, and response note

charting by exception Explanation: The team would most likely suggest the use of charting by exception, which is an abbreviated form of documentation. Narrative notes are time-consuming to write and require much reading to learn about a specific problem. The problem, intervention, and evaluation note system simplifies documentation by incorporating the plan of care into the progress notes. The FOCUS system of documentation organizes entries by data, action, and response. This system is broader in its view because a FOCUS can reflect a possible problem area but does not need to be an actual problem.

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?

charting by exception (CBE)

What ensures continuity of care? -reassessment -critical thinking -communication -integration

communication Explanation: Communication ensures continuity of care and provides essential data for revision of. or continuation of care. The acts of reassessment, critical thinking, and integration do not contribute directly to continuity of care.