chapter 4

Checklists

A client with hemiplegia has been admitted to the health agency. The nurse who cares for the client has a fixed routine of cleaning, feeding, and administering medicines to the client. Which of the following should the nurse use to record these details?

To have up-to-date information on which to base clinical decisions

A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?

Cued or checklist forms

A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?

To communicate effectively with other health care team members

After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?

Itchy skin

Examples of objective data include all the following except:

Insurance companies audit client records to ensure that billing is accurate

How does the client's medical record affect financial reimbursement? (select all that apply.)

Progress notes

The nurse is reviewing the patient's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the patient's status?

Hyperactive bowel sounds are heard in all four quadrant

The nurse is reviewing the patient's medical record. Which does the nurse recognize as accurate documentation?

Health care providers can receive significant incentive payments

The nursing manager explains to the nurses that it is important for the clients to be able to access their own medical records and the new electronic health record system will provide that opportunity. The nurse would identify which of the reasons this is so important?

"I am very happy with my life right now"

Which statement by an adolescent female client admitted for excessive weight loss and dehydration requires validation by the nurse?

draw a line through the error, writing "error" and initialing.

If the nurse makes an error while documenting findings on a client's record, the nurse should

It provides quick access to abnormal findings.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?

charting by exception

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?

validate all data before documentation of the data.

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should

Ask the other nurse to read back what first nurse reported

A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?

Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.

A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?

Progress notes

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?

Reassess blood pressure

The nurse identifies the UAP recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?

avoid slang terms or labels unless they are direct quotes.

The nurse is preparing to document assessment findings in a client's record. The nurse should

SBAR

The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?

•Bowel sounds are hyperactive in all 4 quadrants. •Coarse rhonchi noted throughout lung fields •Left dorsalis pedis pulse weaker than right.

The nurse is reviewing the patient's medical record. Which of the following does the nurse recognize as accurate documentation? (Select all that apply.)

•Allow for several health team members to view a single chart simultaneously •Ensure that all entries are legible •Enable the graphing of trends in vital signs and assessments •Provide off-site viewing so personnel can note changes in the patient's condition

The nurse knows that computerized medical record systems are expensive and can be complicated, but understands that they can significantly increase patient safety. Some things that an electronic medical record can do are as follows: (Select all that apply.)

"bilateral lung sounds clear."

The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write

•accurate •organized •complete •timely •concise

A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply):

Meaningful use of electronic health records

Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?

•When leaving for lunch •When sending the client for an endoscopy •At shift change •Upon transferring to ICU

The nurse would perform handoff report for which situation? Select all that apply.

Focused

The nurse caring for six clients enters the room of a client who underwent gastrointestinal surgery and assesses vital signs, the abdominal wound, and auscultates bowel sounds before seeing the next client. Which type of assessment did this nurse perform on the client?

Time of the assessment

To make a legal entry into the medical record, the nurse must document what?

Communication

What is the primary purpose of the patient record?

Family concerns

When an agency has policies that require nurses to write focus notes, the nursing documentation can include what?

•What the nurse heard •What the nurse palpated •What the nurse observed

When documenting assessment information in the medical record, what does the nurse know that the assessment information must accurately reflect? Select all that apply.

Limiting abbreviations to those approved for use by the institution.

When documenting the care of a patient, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

Cued or checklist forms

Which assessment form promotes easy and rapid documentation while categorizing information?

Comprehensive

Which assessment is most likely performed when a client is admitted to the hospital?

Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?

"Following oxygen administration, vital signs returned to baseline."

Which of the following data entries follows the recommended guidelines for documenting data?

"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."

Which of the following examples of documentation best exemplifies sound clinical documentation practices?

The client reports worsening pain in the neck when she looks down.

Which of the following should be included in the documentation of subjective data in the nurse's findings from the physical examination of the head and neck in the client with acute neck pain?

• Document patient information immediately. •Designate a person to document during emergencies. •Organize patient data logically, using a timed sequence.

Which strategy reduces documentation errors? Select all that apply.

pain relief measures.

While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and the

Documentation constitutes a legal record.

Why is effective documentation most important?

•Determining eligibility for reimbursement •Legal document of care •A method to gather research data •Promoting effective communication between caregiver

A legal nurse consultant explains to a group of nursing students that the medial record serves what purpose? Select all that apply.

It allows several health team members to view the patient record simultaneously.

A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?

Specialty area assessment form

A novice nurse is preparing for a physical examination of a client with neurological issues. The nurse takes a copy of the practice's standard assessment form and heads to the examination room, where the client is already waiting. A senior nurse notes the novice nurse's actions and says, "Here, use this form instead; it's an assessment form specifically for the neurological system." This second form is an example of which type of form?

Compare objective findings with subjective findings.

A nurse assesses a pregnant client in her second trimester. The nurse documents the weight of the client and notices that the client has gained 6 pounds over a week. How should the nurse validate this data?

A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight

A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation?

Narrative charting

A nurse charting the medical record for a client knows that which of the following forms of charting involves writing information about the client and client care in chronological order?

Details are often missing

A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?

•Document the findings in a private area, where no other clients can read the nurse's notes •Write entries objectively without making premature judgments or diagnoses

A nurse has completed her physical examination of a client and is recording her findings. Which of the following should she do while documenting? Select all that apply.

Repeating the measurement with a different sphygmomanometer and stethoscope

A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The patient's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

Focused

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?

Draw a line through the error and place initials above the correction.

A nursing instructor is showing the nursing student how to correct an error when documenting on the chart. The instructor directs the student to do the following:

•Communication among health team members •Care planning •Quality assurance •Financial reimbursement •Research

A nursing instructor is teaching students about the importance of prompt and accurate documentation to ensure safe care. The instructor stresses the following as purposes of the medical record. Select all that apply.

Progress notes

A patient with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the patient's chart. The nurse knows to look at what part of the patient's medical record to check the current medical diagnosis?

• Verify the data by having another nurse come in to perform the percussion.

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."

During a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?

Facility level

During an accrediting agency visit, it is found that some patient care standards are not being met. Where should problem solving occur in this instance?

Dark purple-blue area on the right side of chest and on right lower back. Open areas on the left side of the lower lip and above right eye.

During the admission assessment, the nurse notes the client has cuts to her face and bruises on her chest and back. Which of the following demonstrates the most appropriate documentation of these findings?

Place the completed assessment in the medical record.

In order to help out the staff in completing admission tasks during a busy shift, the charge nurse is completing the admission database for a staff nurse. What is the charge nurse's best action?

"Has your diet or exercise changed significantly in the past year?"

On reviewing a client's database following a physical examination, a nurse realizes that the client's weight has been steadily increasing over her past three visits. What follow-up question would be best for the nurse to pose to the client based on this finding?

Leave the room to obtain another armband for the client

The nurse enters a client's room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse's best action?

Narrative notes

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record patient conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?

Evidence in a situation of wrongdoing

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?

focused.

In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed

Verify the data by having another nurse come in to perform the percussion.

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

Use phrases instead of sentences to record data.

A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?

•A description of a large bruise on the client's thigh •The client's weight •The presence of a lump in the client's breast discovered on palpation

A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered?

Client's weight was 200 lb 3 months ago but 125 lb today.

A nurse has just finished taking a client's vital signs and is comparing the results with those from his previous visit 3 months ago. Which of the following situations would require the nurse to validate the data?

•Provides proof for reimbursement •Helps facilities to receive accreditation •Serves as legal evidence •Allows for communication with other heath team members

A nurse is busy caring for several patients but understands the importance of taking the time to chart properly. Charting serves many purposes, which include: (Check all that apply.)

charting by exception

A nurse is caring for a patient who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called:

•The client's weight-lifting routine •The client's family history of cancer •The client's occupation

A nurse is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect? Select all that apply.

Nursing minimum data set

A nurse is conducting client assessments in a long-term care facility. The manager of the facility has requested that the clinical staff use assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas, and time, so that they can compare their results with other long-term care facilities in the nation. Which form should the nurse use?

•A record supplied by a physician in which diagnoses and prescribed treatments are recorded

A nurse is explaining to a new client that the office uses electronic health records (EHRs) for all clients. The client says that at his last office, they used electronic medical records (EMRs). He asks whether these are the same thing. The nurse explains that they are different. Which of the following is a characteristic that is true of an EMR?

The confidentiality of electronic and printed health information

A nurse is having a new client complete a health history form and sign a form acknowledging his rights under the Health Insurance Portability and Accountability Act (HIPAA). The client asks the nurse what HIPAA covers. Which of the following most accurately describes what HIPAA covers?