chapter 4- validating and documenting data (weber)

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?

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

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."

A nursing instructor is teaching a student about the importance of documenting all interventions on the patient record for reimbursement purposes. The instructor knows the student understands when she states which of the following:

"Lack of appropriate charting can affect whether financial payment will be authorized."

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.

-Document the findings in a private area, where no other clients can read the nurses notes -Write entries objectively without making premature judgement or diagnoses

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):

-complete -accurate -timely -organized -concise

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.

-determine ways to validate the data -decide whether the data require validation -identify areas where data are missing

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

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

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

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 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.

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?

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.

The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?

assessment data in the medical record

which assessment is most likely performed when a client is first admitted into a hospital

comprehensive

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?

Repeating the measurement with a different sphygmomanometer and stethoscope

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

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?

ask the other nurse to read back what first nurse reported

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

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

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

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:

charting by exception

what is the primary purpose of the patient record

communication

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

comprehensive

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 constitues a legal record

Why is accurate and effective documentation most important?

documentation constitutes a legal record

A nurse makes an incorrect entry onto a client's paper record during documentation of the assessment data. What is the correct way for the nurse to fix this error?

draw a line through the error, write error and initial entry

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

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

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?

meaningful use of electronic health records

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?

narrative notes

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

validate all data before documentation of the data

an example of an objective finding in an adult client

vital signs

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

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

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

Which strategy reduces documentation errors? Select all that apply.

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

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.

-the clients occupation -the clients family history of cancer -the clients weight-lifting routine

Why do nursing students review medical records? (Select all that apply.)

-to enhance clinical learning -to better understand complex clinical situations

What is the nurse's best defense if a patient alleges nursing negligence?

patients 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?

place the complete assessment in the medical record

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

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?

provides quick access to abnormal findings

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?

reassess blood pressure

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

time of 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