Chapter 4 Nursing

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): accurate organized biased complete concise timely

-complete -accurate -timely -organized -concise

Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? -A patient has ask a nurse if he can read the documentation that his physician wrote in his chart. - A patient wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. -A patient has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. -A patient who resides in Indiana has required hospitalization during a vacation in Hawaii

A patient has ask a nurse if he can read the documentation that his physician wrote in his chart.

The nurse assesses all assigned patients and sits in the nursing station to document assessment data for all patients. This is an example of -Organized charting -Batch charting -Accurate documentation -Point-of-care documentation

Batch charting

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: -narrative -charting -pie charting -batch charting -charting by exception

Charting by exception

Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse? -Charting by exception -Focus charting -Problem-oriented medical record -PIE charting

Charting by exception

While the nurse performs the initial assessment, the client states "This is my first hospitalization and I have had no previous surgeries." How would the nurse document this information? -Client denies prior hospitalizations and surgeries -Client has not been hospitalized before nor has he had any surgery -Client answered no to previous hospitalizations or surgery -Negative for past hospitalizations

Client denies prior hospitalizations and surgeries

A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding? -Client has severe headache, probably related to alcoholism. -Client has a dull, aching pain in the back of his head that began 2 weeks ago. The pain is constant and seems to be worse in the mornings. -Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. -Client reports headache.

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

A nurse is working on a unit for clients with neurological conditions. Which assessment form would the nurse most likely use to document assessment data? -Frequent assessment form -Open-ended form -Ongoing assessment form -Focused assessment form

Focussed Assessment form

A group of nursing students are reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes? A. It replaces the client acuity classification system. B. It directly formulates the nursing diagnoses. C. It creates a data base for care that was not rendered to the client. D. It provides a chronologic source of client assessment data.

It provides a chronologic source of client assessment data.

There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many health care providers questioning the rationale for this change in practice. What potential advantage of EHRs should administrators cite? -Improved continuity of care -Elimination of documentation -Increased influence for the nursing profession -Reduced nursing workload

Improved continuity of care

When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason? A. Health care institutions have established policies regarding documentation. B. It becomes the foundation for the entire nursing process. C. Incorrect conclusions may be made without documentation of initial data. D. It satisfies legal standards established by health care organizations and institutions.

It becomes the foundation for the entire nursing process.

A group of nursing students is reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes? -It creates a database for care that was not rendered to the client. -It replaces the client acuity classification system. -It directly formulates the nursing diagnoses. -It provides a chronologic source of client assessment data.

It provides a chronologic source of client assessment data

What is the name of the information program mandated by the federal government for the initial and ongoing assessment of Medicare and Medicaid clients in the homecare setting? -CAMEL -OASIS -SOAPIE -APIE

OASIS

Mistakes in charting can be costly to both the patient and nurse. The Joint Commission has listed a primary cause for these mistakes as a failure in communication. Life-threatening errors in health care have been labeled as which of the following: -Side effects -Adverse reactions -Sentinel events -Mismanagement

Sentinel Events

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? -Significant differences in charting between nurses due to lack of standardization. -Failure to identify an record patient problems and associated interventions. -Increased workload for nurses in order to complete necessary documentation. -Vulnerability to legal liability since the nurse's safe, routine care is not recorded.

Vulnerability to legal liability since the nurse's safe, routine care is not recorded

A client who had a mastectomy is being discharged home on postoperative day 1. Knowing that the client lives alone, which data would be most important for the nurse to validate for this client? -If the client usually functions independently -If the client has a religious belief regarding illness -If the client has transportation for follow-up appointments -What support systems are in place to assist the client

What support systems are in place to assist the client