Chapter 4: Validating and Documenting Data PrepU

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? a. "It means I need to make sure that all the information I gathered today is reliable and accurate." b. "It means I need to take all of your vital signs one more time." c. "It means I need to have the physician come in and look over your chart to make sure I didn't miss anything." d. "It means that I need you to sign a statement in which you confirm that everything you have shared with me today is true."

a. "It means I need to make sure that all the information I gathered today is reliable and accurate." Validation of data is the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate. Validation does not mean that the nurse must retake all of the client's vital signs, have the physician check the client's chart, or have the client sign a statement.

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 a. "bilateral lung sounds clear." b. "the client's lung sounds were clear on both sides." c. "client's lung sounds were auscultated with stethoscope and were clear on both sides." d. "after listening to client's lung sounds, both lungs appeared clear."

a. "bilateral lung sounds clear." Use phrases instead of sentences to record data. For example, avoid recording: "The client's lung sounds were clear both in the right and left lungs." Instead record: "Bilateral lung sounds clear."

The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC? a. Assessment data in the medical record b. Medical diagnosis c. Standards of nursing care d. Client and family requests

a. Assessment data in the medical record Assessment data provide the basis for the POC that identifies problems, outcomes, and interventions for the client. The POC helps caregivers coordinate and individualize care until discharge.

A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which of the following is an example of a written form of communication that the nurse should use? a. Checklists b. Notepad c. E-mail d. SMS

a. Checklists The nurses can use the checklist method to share the client's health status with other health personnel involved in the client's care. Some other examples of written forms of communication include the nursing care plan, the nursing Kardex, and flow sheets. Notepads, e-mails, and SMSs are not examples of written forms of communication that the nurses should follow.

Which assessment is most likely performed when a client is admitted to the hospital? a. Comprehensive b. Focused c. Shift d. Abbreviated

a. Comprehensive A comprehensive assessment of the client is performed by a hospital nurse on admission. A shift assessment is performed at the beginning of each shift. A focused assessment is a very brief assessment of potential problems. An abbreviated assessment is a term not commonly used but is similar to a focused assessment.

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. a. Document the findings in a private area, where no other clients can read the nurse's notes b. Record all information with a pencil, so that the physician can easily make changes as needed c. Use only complete sentences d. Explain the process used to obtain each piece of data e. Write entries objectively without making premature judgments or diagnoses

a. Document the findings in a private area, where no other clients can read the nurse's notes e. Write entries objectively without making premature judgments or diagnoses When documenting findings, the nurse should keep confidential all information documented in the client record at all times and should write entries objectively without making premature judgments or diagnoses. The nurse should use a pen with nonerasable ink, not a pencil or a pen with erasable ink, to document all findings. The nurse should use phrases instead of sentences to be concise and should record only the data findings, not how they were obtained.

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes? a. Evidence in a situation of wrongdoing b. Evaluate nursing care provided c. Discharge planning for the client d. Reimbursement for care provided

a. Evidence in a situation of wrongdoing The medical record can be used as a legal document to provide evidence of wrongdoing. Quality assurance is conducted to determine whether standards of care are provided to clients and documented in the medical record. Various members of the healthcare team document in the medical record to communicate information and make care decisions and plan for client discharge. Information in the client's medical record is used to determine reimbursement by Medicare, Medicaid, workers' compensation insurance, and third-party insurance companies for care.

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? a. Focused b. Assessment flow chart c. Progress notes d. Nursing minimum data set

a. Focused Some institutions may use assessment forms that are focused on one major area of the body for clients who have a particular problem. Examples include cardiovascular or neurologic assessment documentation forms. An assessment flow chart allows for rapid comparison of recorded assessment data from one time period to the next. Progress notes may be used to document unusual events, responses, significant observations, or interactions because the data are inappropriate for flow records. The nursing minimum data set form has a cued format that prompts the nurse for specific criteria; it is usually computerized and is commonly used in long-term care facilities.

What are the primary frameworks used in conducting a health assessment? Select all that apply. a. Head to toe b. Gordon's c. Body systems d. Analytical e. Functional systems

a. Head to toe c. Body systems e. Functional systems A nursing framework assists in providing organization of the information gathered during an assessment and helps to ensure holistic data is captured. Three major frameworks for organizing assessment data are functional systems, body systems, and head-to-toe assessment. Gordon's functional health assessment focuses on the effects of health and illness on a client's overall quality of life. An analytical framework is not a primary framework for conducting a health assessment on a client.

The nurse is reviewing the client's medical record. Which does the nurse recognize as accurate documentation? a. Hyperactive bowel sounds are heard in all four quadrants. b. Patient is overweight. c. Patient is confused and combative. d. Patient's pain is tolerable.

a. Hyperactive bowel sounds are heard in all four quadrants. Accurate documentation is detailed and explicit. The nurse would recognize bowel sounds are hyperactive in all four quadrants as accurate documentation. The three remaining options are judgment without specific supporting information. The client's weight and pain rating should be specified. Specific comments and behaviors should be documented to support the judgment of confusion and combativeness.

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? a. Narrative notes b. SOAP notes c. Focus charting d. Charting by exception

a. Narrative notes One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

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? a. Progress notes b. Plan of care c. Clinical pathway d. Flow sheets

a. Progress notes Multiple members of the health care team document in a progress note the client's progress toward recovery. The plan of care details individualized goals, outcomes, and interventions for the client, while a critical pathway is a multidisciplinary tool that identifies a standard plan of care for a specific client population. Flow sheets are used to document routine, scheduled nursing assessments and assist in the analysis of trends in client data.

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 client'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? a. Repeating the measurement with a different sphygmomanometer and stethoscope b. Asking the physician to come in and take the client's blood pressure c. Asking the client whether his diet has changed in the past year d. Asking the client whether his exercise habits have changed recently

a. Repeating the measurement with a different sphygmomanometer and stethoscope The most appropriate method of validation in this case would be to simply retake the client's blood pressure with a different sphygmomanometer and stethoscope. Given the nurse's work experience, it is unlikely that the discrepancy is due to improper technique, thus having the physician take the client's blood pressure is not warranted. Given the client's long history of hypertension and that his weight has not changed, it seems unlikely that the discrepancy could be explained by improved diet or exercise.

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? a. To communicate effectively with other health care team members b. To provide protection from liability in the case of a lawsuit c. To avoid penalties imposed by the federal government d. To aid the nurse's recall of client information

a. To communicate effectively with other health care team members The primary reason for documentation of assessment data is to promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care. Although documentation may protect a practice from liability, help avoid penalties, and aid the nurse's recall of client information, none of these is the primary reason for documentation.

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? a. To have up-to-date information on which to base clinical decisions b. To be able to verify what care has been given c. To communicate with other health care providers d. To be able to update the plan of care

a. To have up-to-date information on which to base clinical decisions All the responses are correct; however, the best answer is that prompt documentation allows health team members to use up-to-date assessment information to make clinical decisions.

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? a. Vulnerability to legal liability since the nurse's safe, routine care is not recorded. b. Increased workload for nurses in order to complete necessary documentation. c. Failure to identify an record client problems and associated interventions. d. Significant differences in charting between nurses due to lack of standardization.

a. Vulnerability to legal liability since the nurse's safe, routine care is not recorded. A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

The nurse would perform handoff report for which situation? Select all that apply. a. When leaving for lunch b. When sending the client for an endoscopy c. At shift change d. Upon transferring to ICU e. When assessing other clients on the unit

a. When leaving for lunch b. When sending the client for an endoscopy c. At shift change d. Upon transferring to ICU Handoff, or transfer of care of a client from one health care provider to another should occur when there is a transfer of responsibility for the care of the client to another. Lunch breaks, transferring the client to ICU or procedural areas and at shift change all require a handoff. When the nurse is assessing other clients, the nurse retains responsibility for the client and no handoff is needed.

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): a. accurate b. organized c. complete d. biased e. timely f. concise

a. accurate b. organized c. complete e. timely f. concise Quality assessment data remain confidential, accurate, concise, complete, organized, and timely. Findings are not biased but factual.

The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form a. prevents missed questions during data collection. b. covers all the data that a client may provide. c. clusters the assessment data with nursing diagnoses. d. establishes comparability of data across populations.

a. prevents missed questions during data collection. Cued or checklist forms prevents missed questions.

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should a. validate all data before documentation of the data. b. document the data after the entire examination process. c. record the nurse's understanding of the client's problem. d. use medical terms that are commonly used in health care settings.

a. validate all data before documentation of the data. Validation of data verifies the assessment data that you have gathered from the client. It consists of determining which data require validation, implementing techniques to validate, and identifying areas that require further assessment data.

Which statement by an adolescent female client admitted for excessive weight loss and dehydration requires validation by the nurse? a. "I exercise at least two hours every day" b. "I am very happy with my life right now" c. "My mouth and lips feel very dry" d. "I have been having a lot of nausea lately"

b. "I am very happy with my life right now" Adolescents, especially females are at risk for anorexia nervosa. This illness has a psychological aspect to it in which the adolescent feels that she is fat and therefore unattractive, no matter what she weighs. A female admitted for severe weight loss and dehydration is not likely to be happy with her life at the present time. Excessive exercising is often seen in adolescent female in order to burn off what little calories they eat during the day. Dehydration will make the mouth and lips dry. Nausea is common in anorexia because the stomach is still secreting acid but there is little food being digested.

The nurse is admitting a client to a medical unit. The client is concerned that all of his private health information is on the computer and an error may occur. What is the most appropriate response of the nurse? a. "Computers do make errors from time to time, that is why we are extra careful." b. "The electronic medical record is one of the tools we use to keep you safe." c. "I can use a paper chart if you prefer." d. "We back up all of our files so that your health information is always secure."

b. "The electronic medical record is one of the tools we use to keep you safe." The data demonstrates the electronic health record has improved client safety by decreasing medication errors and quality issues. Using a paper chart is not an appropriate response. Telling the client that computers do make errors is incorrect, as the data is only as accurate as the person putting it in. Telling the client files are backed up does not address the concern for safety.

A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered? Select all that apply. a. A description of gall bladder surgery the client had 10 years ago b. A description of a large bruise on the client's thigh c. The client's weight d. The presence of a lump in the client's breast discovered on palpation e. A 24-hour recall of what the client has eaten

b. A description of a large bruise on the client's thigh c. The client's weight d. The presence of a lump in the client's breast discovered on palpation Subjective data include information that the client or significant others tell the nurse and typically consist of biographic data, present health concern(s) and symptoms, personal health history, family history, and lifestyle and health practices information. Objective data are what the nurse observes through inspection, palpation, percussion, or auscultation.

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? a. A record that covers the more comprehensive health status of the client b. A record supplied by a physician in which diagnoses and prescribed treatments are recorded c. A record that is intended for sharing data with many different types of health care providers d. A record designed to reach out beyond the health organization that originally obtains the data

b. A record supplied by a physician in which diagnoses and prescribed treatments are recorded The two terms electronic health records and electronic medical records are often used in place of each other. However, they represent two different forms of electronic documentation. The term EMR, which existed before the term EHR, referred to medical records supplied by physicians who made medical diagnoses and prescribed treatments. The more recent term EHR is more commonly used as it refers to the more comprehensive health status of the client, not just the medical status. Thus the EHR may be used by a variety of health care providers, not just physicians. EHRs focus on the total health (emotional, physical, social, spiritual) of the client and are designed to reach out beyond the health organization that originally obtains the client data.

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain? a. Abdominal pain x 2 weeks, no medications taken, denies diarrhea or constipation b. Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10 c. Abdominal pain most likely due to client's unhealthy lifestyle and poor eating habits d. Bowel sounds are present in all four quadrants, all organ within normal limits

b. Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10 Documentation should be concise and precise. The nurse should record what the client tells her in detail. Nurses should not make judgments or diagnosis about the information gathered until all data has been collected and validated. The use of the statement "within normal limits" should not be used-the nurse should document the actual data that was collected.

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? a. Open-ended forms b. Cued or checklist forms c. Integrated cued checklist d. Nursing minimum data set

b. Cued or checklist forms Cued or checklist forms promote easy and rapid documentation while categorizing information. Open-ended forms are the traditional forms that individualize information and allow the narrative description of problems. An integrated cued checklist combines assessment data with identified nursing diagnoses. A nursing minimum data set is usually a computerized document and is often used in long-term care facilities.

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? a. Multiple bruises and cuts on client's body. Client states she fell down a flight of stairs. b. 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. c. Bruises and cuts to face and torso. Client appears to have been severely beaten by her husband. d. Bruises on chest and back with multiple cuts on her face.

b. 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. Documentation needs to be clear and specific. Documentation should describe and provide a location of the areas. Documentation should not include any assumptions or judgements.

A nurse has completed assessing a client and now must validate the collected data. What are the steps that the nurse should follow? Select all that apply. a. Verify every piece of data that was assessed. b. Decide whether the data require validation. c. Determine ways to validate the data. d. Repeat all objective assessments. e. Identify areas where data are missing.

b. Decide whether the data require validation. c. Determine ways to validate the data. e. Identify areas where data are missing. The steps involved in validation of data include deciding whether the data require validation, determining ways to validate the data, and identifying areas where data are missing. The nurse need not verify every piece of data that was assessed unless there are discrepancies or gaps in the data collected. The nurse need not repeat all objective assessments, unless they are abnormal or inconsistent with other findings.

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? a. The charting format is not ethical b. Details are often missing c. Subjective information is often missing d. It reflects poor assessment skills on the part of the nurse

b. Details are often missing CBE may pose legal problems, because details are often missing. CBE does not omit subjective assessment, CBE is an ethical form of charting, and the question does not indicate that the assessment skills of the nurse are lacking in any form.

During an accrediting agency visit, it is found that some client care standards are not being met. Where should problem solving occur in this instance? a. Patient level b. Shift level c. Department level d. Facility level

d. Facility level Accrediting agencies such as The Joint Commission or state agencies such as departments of health can establish standards and audit client records to evaluate the quality of care provided. The Joint Commission accreditation is often required for facilities to obtain Medicare and Medicaid funding, so hospitals are motivated to comply with the standards in documentation and care that The Joint Commission sets.

The hospital where a nurse works is converting from a paper-based documentation system to a computer-based one. The nurse recognizes that which of the following are advantages of computer-based over paper-based systems? Select all that apply. a. Freedom from having to satisfy legal standards b. Elimination of redundant data collection by other health care team members c. Increased likelihood that clients will receive life-saving treatment d. Potential lowered risk of hospital-acquired infections e. Ability to link the client's health record to other documents f. Greater security and privacy of client's health information

b. Elimination of redundant data collection by other health care team members c. Increased likelihood that clients will receive life-saving treatment d. Potential lowered risk of hospital-acquired infections e. Ability to link the client's health record to other documents With the advent of computer-based documentation systems, these databases can link to other documents and health care departments, eliminating repetition of similar data collection by other health team members. The use of electronic health records also increases the likelihood that clients received life-saving treatments and may lower the risk of hospital-acquired infections. Computer-based systems still must meet legal standards and do not offer greater security and privacy of the client's health information.

When charting by exception is used in a health care agency, the most important aspect of this method is what? a. Organizing new forms for the nursing staff b. Identifying the standards and norms for the institution c. Training new nurses in writing charting by exception notes d. Pulling together a group of experts to teach agency staff

b. Identifying the standards and norms for the institution Clearly identifying the standards and norms and educating all users takes time and significant commitment from the agency using charting by exception. Organizing new forms for the nursing staff, training new nurses, and acquiring teachers for agency staff may be important, but they are not the most important aspect of this method.

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? a. Evidence of validation of all vital sign measurements b. Meaningful use of electronic health records c. Data backup of all digital files d. Use of a standard method of data communication

b. Meaningful use of electronic health records Since the Health Information Technology for Economic and Clinical Health Act of 2009 was adopted, there has been a slow but steady increase in use of EHRs by health care agencies and primary health care providers. To encourage the use of EHRs, Medicare and Medicaid began to offer federal incentive payments of $2 million or more to health care providers and hospitals to use EHR technologies. In addition, penalties will be applied to providers unable to demonstrate meaningful use of EHRs by 2015.

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? a. Document the highlights of the physical exam. b. Place the completed assessment in the medical record. c. File the admission database for nurse only access. d. Omit the fall risk assessment since the client is a young adult.

b. Place the completed assessment in the medical record. The database should be placed in the medical record for access by all healthcare professionals who may need to review the client's information. The nurse should allow some time for documentation of findings and analysis of data. In addition to positive findings, it is essential to document absence of findings because, in the legal world, "if it's not documented, it's not done." The database should be completed in its entirety on admission. The client may be young, but an initial fall assessment score should be assessed.

A client with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the client's chart. The nurse knows to look at what part of the client's medical record to check the current medical diagnosis? a. Demographic data sheet b. Progress notes c. Admission history d. Medication record

b. Progress notes All members of the healthcare team use the progress notes to record the client's progress and any changes. The demographic sheet contains the client's personal information. The admission history states the problems upon admission. The medication record lists all medications that the client has been and are scheduled to be given.

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? a. PIE b. SBAR d. DAR d. SOAP

b. SBAR Verbal communication of a change in a client's condition would be most effective if the nurse used SBAR as it provides a standardized format and structure for communication. PIE, DAR and SOAP are all types of progress notes.

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. a. Description of a lesion that the nurse observes on the client's arm b. The client's occupation c. The client's blood pressure d. The client's family history of cancer e. The client's weight-lifting routine

b. The client's occupation d. The client's family history of cancer e. The client's weight-lifting routine Subjective data include information that the client or significant others tell the nurse and typically consist of biographic data, present health concern(s) and symptoms, personal health history, family history, and lifestyle and health practices information. Objective data are what the nurse observes through inspection, palpation, percussion, or auscultation.

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record? a. To transmit health records between insurance companies b. To investigate the quality of care in the agency c. To inform family and others concerned about the client's care d. To release the entire health record for research

b. To investigate the quality of care in the agency Medical records may occasionally be used to investigate the quality of care in the agency. A medical record is not used to transmit health records between insurance companies, to inform family and others concerned about the client's care, or to release the entire health record for research, as these actions would jeopardize the individual's right to privacy.

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. Use an eraser to remove any error in the document. b. Use phrases instead of sentences to record data. c. Record how data findings were obtained. d. Record "normal" for all normal findings if required.

b. Use phrases instead of sentences to record data. The nurse should document assessments using phrases instead of sentences to avoid the use of too many redundant words and to focus only on the essential (information) terms. Errors in documentation should be corrected by drawing one line through the entry, writing "error," and initialing the entry; an eraser should not be used to remove any error in the document. A pencil or pen with erasable ink should never be used in documentation. The nurse needs to record only the data findings, not how the data findings were obtained, in precise terms. All findings should be recorded as per the values obtained during assessment in descriptive terms, even if the finding is normal.

The nurse is preparing to document assessment findings in a client's record. The nurse should a. write in complete sentences with few abbreviations. b. avoid slang terms or labels unless they are direct quotes. c. record how the data were collected. d. use the term "normal" to describe nonpathological findings.

b. avoid slang terms or labels unless they are direct quotes. Use correct grammar and spelling. Use only abbreviations that are acceptable and approved by the institution. Avoid slang, jargon, or labels unless they are direct quotes.

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? a. "Client visibly agitated during assessment and unwilling to continue." b. "Client became upset and terminated assessment." c. "During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." d. "During chest auscultation, client decided that she could no longer participate in assessment and removed herself from the room."

c. "During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." Documentation should be as objective and precise as possible. Answers A and B attribute the client's behavior to being agitated and upset, both of which are terms lacking in precision and objectivity. Answer D is more objective, but answer C provides the most detailed, objective account of what transpired.

Which of the following data entries follows the recommended guidelines for documenting data? a. "Patient is overwhelmed by the diagnosis of pancreatic cancer." b. "Patient kidneys are producing sufficient amount of measured urine." c. "Following oxygen administration, vital signs returned to baseline." d. "Patient complained about the quality of the nursing care provided on previous shift."

c. "Following oxygen administration, vital signs returned to baseline." The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. The nurse should also avoid generalizations such as "seems comfortable today." The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner.

A nursing instructor is teaching a student about the importance of documenting all interventions on the client record for reimbursement purposes. The instructor knows the student understands when she states which of the following: a. "Medicaid and Medicare pay the same, even though the care may not be charted." b. "Third-party insurance companies do not count on the client's record to show care has been given." c. "Lack of appropriate charting can affect whether financial payment will be authorized." d. "Diagnostic-related groups are not supported by documentation in the client's record."

c. "Lack of appropriate charting can affect whether financial payment will be authorized." Medicare, Medicaid, worker's compensation, and third-party insurance companies depend on information in the chart to provide for reimbursement for care.

Which of the following examples of documentation best exemplifies sound clinical documentation practices? a. "Client is anxious during questioning regarding health history and family history." b. "Abnormal chest sounds noted during posterior chest auscultation." c. "Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter." d. "Client reports sharp pain to chest on deep inspiration."

c. "Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter." Answer C is both precise and objective, while stating the client is "anxious" in answer A is not objective. Labelling chest sounds as "abnormal" or simply describing pain as "sharp" in answers B and D both indicate a lack of detail.

A nursing student has learned the importance of documenting only appropriate and accurate information. Which of the following is an appropriate notation in a client's record? a. "Patient is upset with her husband." b. "Dr. Smith did not answer the client's questions." c. "Patient stated dull, aching pain in the lower abdomen-rates as a 5 on scale of 1-10." d. "Patient spoke to nurse in a sarcastic tone."

c. "Patient stated dull, aching pain in the lower abdomen-rates as a 5 on scale of 1-10." Assessment data that the nurse enters into the client's record must accurately reflect what was observed, heard, auscultated, palpated, percussed, or smelled. Subjective data are documented using the client's exact words. The client's description of pain is the only datum that should be entered into the chart.

Examples of objective data include all the following except: a. Coughing b. Foul-smelling discharge c. Reddened skin d. Itchy skin

d. Itchy skin Objective data are information obtained during the physical examination. They include all data gathered by inspection, palpation, percussion, and auscultation. Coughing is audible to the examiner, foul-smelling discharge can be smelled, and reddened skin can be noted on inspection. Itchy skin is a subjective report from the client experiencing it.

A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation? a. A blood pressure reading of 110/70 mm Hg in a competitive athlete b. A pulse rate of 98 in a 10-year-old boy c. A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight d. A temperature of 97 degrees in an elderly woman

c. A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight Not every piece of data you collect must be verified. For example, you would not need to verify or repeat the client's pulse, temperature, or blood pressure unless certain conditions exist. The blood pressure reading, pulse rate, and temperature listed in the answer choices are all within the normal range given the contexts provided. A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and who appears to be of normal weight, however, would be cause for validation, as there is a significant gap between the finding of the client's weight and the client's appearance.

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? a. Communicate face to face with good eye contact b. Provide documentation of the data you are sharing c. Ask the other nurse to read back what first nurse reported d. Have the other nurse speak with the attending physician to clear up any misunderstandings

c. Ask the other nurse to read back what first nurse reported When reporting over a telephone, ask the receiver to read back what he or she heard you report and document the phone call with time, receiver, sender, and information shared. It would not be feasible to communicate face to face or provide documentation when speaking on the phone. Also, it would not be feasible or appropriate to have the attending physician speak with the other nurse, as the physician may not be available and would not likely be able to clarify the first nurse's assessment findings anyway.

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

c. Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. As this is subjective data, the nurse should record it as the "client reports" instead of the "client has," to clarify that this is based on the client's perception. The nurse should use phrases instead of sentences for brevity. Finally, the nurse should record complete information and details for all client symptoms or experiences, not just, "Client reports headache."

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: a. Erase thoroughly and then rewrite the entry. b. Black out the incorrect information with a marker and write the correct entry above. c. Draw a line through the error and place initials above the correction. d. Use whiteout to make the chart appear neat and rewrite the entry.

c. Draw a line through the error and place initials above the correction. Nurses need to correct errors when documenting to make sure the record is accurate. In written records, they need to draw a line through the error and place initials above the correction. A nurse should never erase, black out information, or use whiteout.

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? a. It maximizes compliance with standards of documentation. b. It disables the graphing of trends in vital signs or assessment data. c. It allows several health team members to view the client record simultaneously. d. It automatically corrects both spelling and grammar.

c. It allows several health team members to view the client record simultaneously. Electronic medical records allow several health care team members to view the client record simultaneously.

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? a. Focus charting b. SOAP charting c. Narrative charting d. PIE charting

c. Narrative charting Narrative charting involves writing information about the client and client care in chronological order. In SOAP charting, everyone involved in the client's care makes entries in the same location in the chart. Focus charting follows a data, action, and response (DAR) model to reflect the steps in the nursing process. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

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? a. The confidentiality of electronic protected health information b. The confidentiality of printed protected health information c. The confidentiality of electronic and printed health information d. The confidentiality of the client's financial information

c. The confidentiality of electronic and printed health information All documented information in the client record, whether electronic or printed, should be kept confidential. Most agencies require nurses to complete the HIPAA training to ensure that the use, disclosure of, and requests for protected information are applied only to intended purposes and kept to a minimum, thus preserving confidentiality.

To make a legal entry into the medical record, the nurse must document what? a. Laboratory tests ordered b. Attending physician c. Time of the assessment d. Nature of the assessment

c. Time of the assessment The nurse must record normal assessment data, abnormal assessment data, and the time of the assessment. The nurse does not have to document laboratory tests ordered, the attending physician, or the nature of the assessment.

Which assessment form provides a nurse with the ability to compare nursing data across clinical populations, settings, geographical areas, & time? a. Open-ended forms b. Cued or checklist forms c. Integrated cued checklist d. Nursing minimum data set

d. Nursing minimum data set The nursing minimum data set establishes comparability of nursing data across clinical populations, settings, geographic areas, and time. Open-ended forms, cued or checklist forms, and integrated cued checklists do not provide such comparability of nursing data.

A nurse is recording some vital signs in a 12-year-old girl's chart when the girl asks why the nurse is writing all that information down. Which of the following should the nurse mention to this client as reasons for documenting assessment findings? Select all that apply. a. To eliminate the possibility of diagnosing new problems b. To ensure that only the nurse is aware of the assessments c. To prevent delays in carrying out the plan of care d. To determine the educational needs of the client

c. To prevent delays in carrying out the plan of care d. To determine the educational needs of the client Two of the reasons the nurse should document assessment findings are to determine the educational needs of the client and to prevent delays in carrying out the plan of care. Documentation acts as a source of information to help diagnose new problems rather than eliminating the possibility of diagnosing new problems. Documentation ensures that the information is accessible to all members of the health care team, not just the nurse; this enables effective communication between the team members.

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? a. Repeat the percussion using the nondominant hand. b. Clarify the data by asking whether the client has experienced any trouble breathing lately. c. Verify the data by having another nurse come in to perform the percussion. d. Confirm that the client has truly never been a smoker by asking him.

c. Verify the data by having another nurse come in to perform the percussion. The most appropriate method of validation in this case would be to have another nurse come in to perform the percussion. We know that the nurse is inexperienced, and with all of the other information supplied, it is much more likely that the discrepancy is due to improper percussion technique or faulty interpretation of the sound than it is to the client actually having emphysema. Repeating the procedure with the nondominant hand is not likely to change the results. If the client appears healthy and has not reported breathing difficulty, it is not likely that he has emphysema. If the client has already denied smoking, asking him again will likely only insult him.

One disadvantage of the open-ended assessment form is that it a. does not allow for individualization. b. asks standardized questions. c. requires a lot of time to complete. d. does not provide a total picture of the client.

c. requires a lot of time to complete. Open-ended forms (traditional form) requires a lot of time to complete the database.

When using the SBAR communication tool to inform the physician of a client's high blood pressure and anxiety, the nurse should make which statement first while on the phone with the physician? a. "Your client has a high blood pressure and takes antihypertensives at home." b. "The client's blood pressure is 180/85, pulse is 94 and client appears anxious." c. "You need to come assess this client at the bedside." d. "I am a registered nurse caring for your client."

d. "I am a registered nurse caring for your client." The S in SBAR stands for situation. The nurse should first identify his/her self, then provide background information, followed by assessment data, and the nurse's recommendation. The other information in the answer options is relevant and should be relayed to the physician; but the first action is to identify self.

The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems? a. Safety among client populations decreases b. Pharmacy orders are electronically verified c. Physician notes are more secure d. Client safety increases

d. Client safety increases Although implementing a computerized system is expensive and requires much planning and education, such systems significantly increase client safety. Computerized medical records do not decrease client safety, make physician notes more secure, or verify pharmacy orders.

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? a. Data base b. Problem list c. Plan of care d. Progress notes

d. Progress notes 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.

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? a. Initial assessment form b. Frequent assessment form c. Ongoing assessment form d. Specialty area assessment form

d. Specialty area assessment form Some institutions may use assessment forms that are focused on one major area of the body for clients who have a particular problem, known as focused or specialty area assessment forms. Examples include cardiovascular or neurologic assessment documentation forms. Initial assessment forms are broader, more comprehensive assessment forms that are used for a client's first visit. Frequent or ongoing assessment forms are flow charts that help staff record and retrieve data for frequent reassessments.

A nurse is documenting a skin condition that she has observed while examining a client. Which of the following descriptions would be most appropriate to include in the client's chart? a. Abnormal skin observed on the client's right anterior forearm b. Skin normal everywhere except on the client's right anterior forearm c. Client's skin in poor condition on the right anterior forearm d. Three lesions, 5 mm in diameter, producing purulent yellow drainage on the client's right anterior forearm

d. Three lesions, 5 mm in diameter, producing purulent yellow drainage on the client's right anterior forearm Avoid documenting with general nondescriptive or nonmeasurable terms such as normal, abnormal, good, fair, satisfactory, or poor. Instead, use specific descriptive and measurable terms (e.g., 3 inches in diameter, red excoriated edges, with purulent yellow drainage) about what you inspected, palpated, percussed, and auscultated.

If the nurse makes an error while documenting findings on a client's record, the nurse should a. erase the error and make the correction. b. obliterate the error and make the correction. c. draw a line through the error and have it witnessed. d. draw a line through the error, writing "error" and initialing.

d. draw a line through the error, writing "error" and initialing. Errors in documentation are usually corrected by drawing one line through the entry, writing "error," and initialing the entry. Never obliterate the error with white paint or tape, an eraser, or a marking pen. Keep in mind that the health record is a legal document.

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 a. progressive. b. specific. c. checklist. d. focused.

d. focused. Some institutions may use assessment forms that are focused on one major area of the body for clients who have a particular problem. These forms are usually abbreviated versions of admission data sheets, with specific assessment data related to the purpose of the assessment.

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 a. cause of the pain. b. client's caregiver. c. client's occupation. d. pain relief measures.

d. pain relief measures. Record complete information and details for all client symptoms or experiences. For example, do not record: "Client has pain in lower back." Instead record: "Client reports aching-burning pain in lower back for 2 weeks. Pain worsens after standing for several hours. Rest and ibuprofen used to take edge off pain. No radiation of pain. Rates pain as 7 on scale of 1 to 10."