Chapter 4: Validating and Documenting Data

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

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

A nurse who is new to the health clinic and who recently graduated from a nursing program tells a client at the end of an interview that data the nurse has just collected from the client needs to be validated. The client, an elderly gentleman, gives the nurse a strange look and says, "Validate my data? What does that mean?" How should the nurse respond to this client?

"It means I need to make sure that all the information I gathered today is reliable and accurate."

The nurse is reviewing the client'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 client's status?

Progress notes

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

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

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):

1. accurate 2. organized 3. complete 4. timely 5. concise

One of the goals of nursing is to provide care that is safe to clients. What is the best way for nurses to realize this goal?

By continual communication with all members of the health care team

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?

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

A nurse has completed a comprehensive assessment on a client. Which of the following is an accurate way to document client concerns?

Client expresses concerns regarding new blood pressure medication. "I am concerned my blood pressure will go too low."

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

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

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

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

After performing a comprehensive assessment on a new client, the nurse documents the following findings. Which documentation follows acceptable documentation guidelines?

Client states, "I don't want to eat or do anything."

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?

Cued or checklist forms

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?

Details are often missing

Why is accurate and effective documentation most important?

Documentation constitutes a legal record.

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

Evidence in a situation of wrongdoing

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?

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?

Focused

When charting by exception is used in a health care agency, the most important aspect of this method is what?

Identifying the standards and norms for the institution

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

Insurance companies audit client records to ensure that billing is accurate

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?

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

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?

Leave the room to obtain another armband for the client.

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?

Narrative charting

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

Narrative 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?

Progress notes

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?

Place the completed assessment in the medical record.

The nurse is completing a comprehensive assessment on a new client. The nurse adheres to documentation guidelines by charting which of the following?

Recent changes in hearing; client states, "I cannot hear high-pitched sounds"; Weber and Rinne tests confirmed sensory hearing loss.

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?

SBAR

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?

To communicate effectively with other health care team members

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?

The confidentiality of electronic and printed health information

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

Time of the assessment

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?

Use phrases instead of sentences to record data.

The nurse is providing care to a client who has had a significant change in their vital signs and worsening symptoms. How should the nurse communicate these new findings to the health care provider?

Use the SBAR model.

A new order for intravenous (IV) antibiotics has been prescribed for a female client who is hospitalized. The nurse reviews the client's chart, which indicates no known drug allergies and an admission diagnosis of a urinary tract infection (UTI). What is the first action of the nurse?

Verify whether the client has allergies.

A nurse is caring for a client 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:

charting by exception

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

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

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

focused.

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

pain relief measures.

During the chest auscultation portion of 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?

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

The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form

prevents missed questions during data collection.

One disadvantage of the open-ended assessment form is that it

requires a lot of time to complete.

The nurse completes a focused assessment of a wound. Which of the following demonstrates adherence to documentation guidelines?

right malleolus wound 1.2 in. wide x 1.6 in. length (3 cm wide x 4 cm length), .4 in. (10 mm) depth, quarter size yellow slough distal end of the wound