Chapter 4

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? Increased influence for the nursing profession Elimination of documentation Improved continuity of care Reduced nursing workload

Improved continuity of care Explanation: Research has shown that EHRs can improve the continuity of care that clients receive. EHRs are not noted to increase the influence of the nursing profession or reduce workload. EHRs are a form of documentation, not an elimination of documentation.

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? SOAP SBAR PIE DAR

SBAR Explanation: 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 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 Data base Plan of care Problem list

Progress notes Explanation: 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.

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

"Following oxygen administration, vital signs returned to baseline." Explanation: 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 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? Demographic data sheet Medication record Admission history Progress notes

Progress notes Explanation: 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.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing? Focus charting Narrative charting PIE charting SOAP charting

SOAP charting Explanation: The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

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): biased complete organized accurate concise timely

accurate organized complete timely concise Explanation: Quality assessment data remain confidential, accurate, concise, complete, organized, and timely. Findings are not biased but factual.

The nurse uses the SBAR model when reporting on clients at the change of shift. This type of report incorporates what part of the nursing process? nursing diagnosis assessment implementation evaluation

assessment Explanation: One component of SBAR that is the same as the nursing process is assessment. The others, while part of the nursing process, are not used in the SBAR model. The other components of SBAR are situation, background, and recommendations.

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: pie charting narrative charting charting by exception batch charting

charting by exception Explanation: Charting by exception uses predetermined standards and norms to record only significant assessment data, and only abnormal findings require additional documentation. Narrative charting is done using unstructured paragraphs to record assessments and other activities. Pie charting includes stating the problem, interventions, and evaluation. Batch charting is waiting until the end of shift or after all clients have been assessed to chart.

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. establishes comparability of data across populations. clusters the assessment data with nursing diagnoses. covers all the data that a client may provide.

prevents missed questions during data collection. Explanation: Cued or checklist forms prevents missed questions.

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

A client has ask a nurse if he can read the documentation that his physician wrote in his chart. Explanation: Among the provisions of HIPAA are clients' rights to see and read their medical records. Negotiation with an insurance provider, the necessity of a second opinion, and out-of-state care are aspects of care that fall within the specific auspices of HIPAA.

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. Care planning Shift reporting Research Financial reimbursement Quality assurance Communication among health team members

Communication among health team members Care planning Quality assurance Financial reimbursement Research Explanation: The medical record serves many purposes. It is a legal document. It facilitates communication, care planning, quality assurance, financial reimbursement, education, and research. Giving a shift report does not come from the legal document and usually is in the form of SBAR.

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 Integrated cued checklist Open-ended forms Nursing minimum data set

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

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. Explanation: 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.

The nurse completes documentation for a client. Which statement should be questioned?.

Dressing on lower leg has some purulent drainage Explanation: The term "some" should be quantified. The amount of drainage on the dressing should be measured. The other stat

A researcher in a health care facility is conducting a study without IRB approval. The researcher knows that this information is limited to what? Verification of laboratory testing Financial reimbursement Internal quality improvement Pain management

Internal quality improvement Explanation: At times, professionals collect data without IRB approval; however, these studies are limited to internal quality improvement, and data can never be reported to or used by any outside group. Therefore, pain management, financial reimbursement, and verification of laboratory testing are incorrect choices.

What statement about batch charting is most accurate? It facilitates completion in a timely manner. It makes the chart available to multiple users. It provides clear documentation. It contributes to many potential errors.

It contributes to many potential errors. Explanation: Batch charting (waiting until the end of shift or until all clients have been assessed to document) contributes to many potential errors. If you wait to record, you may forget important information or chart assessment data on the wrong client.

A client is being discharged home. The discharge note that the nurse writes for this client provides information for what purpose? A summary of the medical course of the client while in the hospital Information that is only useful for an internal audit Maintaining an accurate list of medications the client has taken Resources and strategies for managing the client at home

Resources and strategies for managing the client at home Explanation: Discharge assessment information is used to identify necessary resources and strategies for successful home management. This information is useful for social work, physical and occupational therapies, and follow-up care by the nurse and provider when returning to the outpatient setting. Discharge assessments do not provide information that is only used in internal audits; they are not summaries of the medical course of the hospitalized client, nor are they used for maintaining an accurate list of medications the client has taken.

Mistakes in charting can be costly to both the client 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: Mismanagement Sentinel events Adverse reactions Side effects

Sentinel events Explanation: The Joint Commission refers to life-threatening errors in health care reported as "sentinel events." Adverse effects and side effects sometimes follow the administration of medications. Mismanagement is not how the Joint Commission labels such mistakes.

A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message? The laboratory assistant is trying to view archived data. The laboratory assistant does not have the correct password. The laboratory assistant does not have the correct access number. The laboratory assistant can only retrieve medical records but cannot view the details.

The laboratory assistant can only retrieve medical records but cannot view the details. Explanation: As per HIPAA regulations, it is important to block the type of information that personnel in various departments can retrieve. Laboratory assistants can retrieve information from the medical records, but they cannot view information in the client's personal history. Even if the laboratory assistant had the correct access number and the password or was trying to view archived data, he or she would not have been able to access a client's personal history.

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

avoid slang terms or labels unless they are direct quotes. Explanation: 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.

While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding? "Reddened area noted on skin surface superficial to client's coccyx." "Impaired skin integrity related to decreased mobility." "Possible pressure ulcer observed over client's coccyx region." "Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm."

"Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm." Explanation: The statement "Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm" is more precise and objective than the other statements listed. It would be presumptive to declare a pressure ulcer. The statement describing a "reddened area" does not describe the size of the lesion. "Impaired Skin Integrity" is a nursing diagnosis.

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

"bilateral lung sounds clear." Explanation: 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."

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 record that covers the more comprehensive health status of the client A record that is intended for sharing data with many different types of health care providers A record designed to reach out beyond the health organization that originally obtains the data

A record supplied by a physician in which diagnoses and prescribed treatments are recorded Explanation: 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.

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

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

The nurse manager reviews documentation completed by a graduate nurse. Which entry should the manager question? Select all that apply Right foot swollen Rates pain as a 6 on a scale of 1 to 10 Vital signs normal Appetite good Reddened area 1 cm x 2 cm on left upper thigh

Appetite good Right foot swollen Vital signs normal Explanation: The manager should question vague documentation such as appetite good, right foot swollen, and vital signs normal. Details should be documented such as the location and size of a reddened area and the objective rating that a client provides about pain level.

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 answered no to previous hospitalizations or surgery Negative for past hospitalizations Client denies prior hospitalizations and surgeries Client has not been hospitalized before nor has he had any surgery

Client denies prior hospitalizations and surgeries Explanation: Documentation of the nursing history, whether it is positive or negative, needs to be objective, measurable, and succinct. The statement about the client denying prior hospitalizations and surgeries meets this goal. The statement about the client not having been hospitalized nor having surgery is wordy. The statement about the client answering no to previous hospitalizations or surgery is inappropriate because it denotes how the information was obtained. The statement about negative for hospitalizations, although succinct, is too succinct and does not address the surgery aspect.

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

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

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

Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10 Explanation: 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 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 the entry Use an eraser to erase the mistake & write the correct data Obliterate the entry with a marking pen write "error", and write the correct data beside it Place correcting tape over the error and enter the correct data on top if the tape

Draw a line through the error, write "error", and initial the entry Explanation: The record is a permanent and legal document. Errors in data entry should be corrected by drawing a line through the incorrect date, writing "error" and then initialed by the nurse. Incorrect data should never be erased, taped, or obliterated by a marking pen.

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

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

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

Evidence in a situation of wrongdoing Explanation: 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.

The nursing instructor is teaching about the importance of good communication and accuracy when documenting on the client chart. Some things that are high-risk errors in documentation are the following: (Check all that apply.) Charting in advance Failing to record changes in a client's condition Documenting the notification of the primary physician when the client's condition changes Falsifying client records Performing an inadequate admission assessment

Falsifying client records Failing to record changes in a client's condition Performing an inadequate admission assessment Charting in advance Explanation: Many high-risk errors in documenting can occur; most of them are related to the documentation of assessment data. These include falsifying client records, failure to record changes, performing an inadequate admission assessment, and charting in advance. Notifying a primary physician of a client's change is proper and within the standard of care and is an expected action by the nurse

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? Nursing minimum data set Focused Progress notes Assessment flow chart

Focused Explanation: 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.

A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data? Open-ended form Focused assessment form Ongoing assessment form Frequent assessment form

Focused assessment form Explanation: The nurse most likely would be using a focused assessment form, one that focuses on the neurologic system because the clients have a specific problem related to neurologic function. An open-ended form would be used for an initial assessment. A frequent or ongoing assessment form could be used to document vital signs or other assessment data to allow rapid comparison of recorded assessment data from one time period to the next.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: Are required to obtain health record information through their insurance company. Need to obtain legal representation to update their health records. Can be punished for violating guidelines. Have the right to copy their health records.

Have the right to copy their health records. Explanation: HIPAA affords clients the right to see and copy their health records, update their health records, and get a list of disclosures a healthcare institution has made for the purposes of treatment, payment, and healthcare operations. Patients have the right to request a restriction on certain uses or disclosures and choose how to receive this health information. HIPAA includes punishments for anyone caught violating client privacy, but these punishments are not directed at the client because HIPAA was implemented to protect the privacy of an individual's health information.

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

Head to toe Body systems Functional systems Explanation: 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? Patient's pain is tolerable. Patient is confused and combative. Patient is overweight. Hyperactive bowel sounds are heard in all four quadrants.

Hyperactive bowel sounds are heard in all four quadrants. Explanation: 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.

A client is being discharged from the hospital after a below-the-knee amputation. The nurse has completed the discharge and gives a copy of the discharge summary with client teaching and medications to the client. The nurse understands the importance of doing a good assessment prior to discharge for which of the following purposes: Identify necessary resources and strategies for successful home management. Make the chart look as complete and thorough as possible. Help ensure that the client feels more comfortable about returning home. Increase the nurse's level of competence.

Identify necessary resources and strategies for successful home management. Explanation: Assessment of the client prior to discharge should indicate that he or she is stable and has received teaching regarding medications and follow-up care. It is used to identify necessary resources and strategies for successful home management. Such assessment is not done to increase the level of competence of the nurse, nor to complete the chart or make the client feel more comfortable. The assessment information is also useful for social work, physical therapy, and occupational therapies, and follow-up care by the nurse and provider when returning to the outpatient setting.

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

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

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? Health care institutions have established policies regarding documentation. It satisfies legal standards established by health care organizations and institutions. Incorrect conclusions may be made without documentation of initial data. It becomes the foundation for the entire nursing process.

It becomes the foundation for the entire nursing process. Explanation: The primary reason for documenting the initial assessment is to provide the health care team with a database that becomes the foundation for care of the client. Although institutions have policies about documentation, incorrect conclusions can occur if data are not documented, and legal standards are in place related to documentation, these are not the primary reason for doing so.

A nursing student is working a 7 a.m. to 3 p.m. shift with a preceptor and is caring for three clients independently. When the preceptor asks if the student has completed charting all her assessments, the student informs the preceptor that she is going to do batch charting. The preceptor informs the student of which of the following about batch charting? It helps you remember important information. It is a useful tool for prioritizing when busy. It contributes to many potential errors. It is fine unless you chart on the wrong client.

It contributes to many potential errors. Explanation: Batch charting, which is waiting until the end of a shift or until all clients have been assessed to document, is not recommended. It contributes to many potential errors. Waiting to chart may also contribute to forgetting important information or charting assessment data on the wrong client.

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? It provides a chronologic source of client assessment data. It creates a data base for care that was not rendered to the client. It directly formulates the nursing diagnoses. It replaces the client acuity classification system.

It provides a chronologic source of client assessment data. Explanation: Assessment documentation provides the health care team with a data base that becomes the foundation for care of the client. It provides a chronological source of client assessment data and progressive record of assessment findings that outline the client's course of care. It helps to identify health problems formulate nursing diagnoses, and plan immediate and ongoing interventions.

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? It provides quick access to abnormal findings. It documents assessments on separate forms. It records progress under problems, interventions, and evaluation. It provides and refers to client's problem by a number.

It provides quick access to abnormal findings. Explanation: Charting by exception provides quick access to abnormal findings as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

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? Focus charting PIE charting Narrative charting SOAP charting

Narrative charting Explanation: 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.

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 Charting by exception SOAP notes Focus charting

Narrative notes Explanation: 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.

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

Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter." Explanation: 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 health care agency has been asked to compensate a client as per a lawsuit filed against it for not following the Health Insurance Portability and Accountability Act (HIPAA) regulations. Which of the following situations is a HIPAA violation? Not informing the auditors of the reason for sharing client health details. Not informing the physician before sharing client-specific information. Not informing health authorities before sharing client-specific information. Not informing a client in writing of the purpose of sharing his or her personal details.

Not informing a client in writing of the purpose of sharing his or her personal details. Explanation: Under HIPAA regulation, health care agencies need to submit a written notice to all clients identifying the uses and disclosures of their health information, such as to third parties for use in treatment or payment for services. The physicians, auditors, and the health authorities do not have the right to share any client information without the client's written consent.

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? APIE CAMEL OASIS SOAPIE

OASIS Explanation: In 2000, the federal government mandated that home care agencies use the Outcome and Assessment Information Set (OASIS) in the initial and ongoing assessment of all clients they care for to qualify for Medicare or Medicaid reimbursement. APIE and SOAPIE are charting formats, and CAMEL is a not a documentation format.

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 Explanation: 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.

When taking a telephone order from a physician, the nurse verifies that he or she understands the order by: Confirming the order with the nurse manager. Repeating the order back to the physician. Asking the physician to summarize the orders given. Faxing the written order to the physician's office.

Repeating the order back to the physician. Explanation: The nurse should repeat every telephone order back to the physician to ensure that he or she correctly understands what was ordered. If the nurse is unsure of the order given by phone, he or she asks the physician to repeat it, but this is not a summarization of the order. Confirming the order with the nurse manager is not an effective means to verify the order because the nurse manager will likely not be available during the telephone conversation.

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? Specialty area assessment form Frequent assessment form Initial assessment form Ongoing assessment form

Specialty area assessment form Explanation: 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.

The nurse is reviewing a SOAPIE note in the client's medical record. The nurse recognizes that "States no longer nauseous and would like something to eat" is which part of the SOAP note. Analysis Subjective Plan Objective Evaluation

Subjective Explanation: This is an example of subjective assessment data because it contains data verbally provided by the client. Objective data are data cues the nurse can observe. Analysis involves the identification of client problems based on the subjective and objective data. The plan outlines the course of action taken to address the problem. Evaluation involves a determination of whether the plan and attainment of expected client outcomes.

After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information as which of the following? Subjective data and objective data Interpretation and inference Data and results Observation and inspection

Subjective data and objective data Explanation: The nursing history and physical examination are also known as subjective and objective data. The nurse interprets this information and draws inferences from it. Observation and inspection are techniques used to perform the physical exam. Data is the information obtained from assessment; the results would be similar to the outcomes achieved by a client.

A nursing instructor is teaching how to document vital signs on the chart. The student demonstrates understanding of accurate documentation when she makes the following recording in the chart: T 37C, P 80, R 12 breaths/min, BP 118/62 mm Hg. Vitals are normal. Vitals are within normal limits. Vitals remain stable.

T 37C, P 80, R 12 breaths/min, BP 118/62 mm Hg. Explanation: When documenting on the chart, the nurse must avoid using words like "normal" or "good" and instead use correct medical terminology. Documentation must be concise and precise. Accuracy permits comparison of current findings with future data to detect changes in client status.

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

Use phrases instead of sentences to record data. Explanation: 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 leave the unit for lunch. What type of communication method should the nurse use? Written handoff Verbal handoff Focus note Patient Assessment Instrument

Verbal handoff Explanation: A verbal handoff is appropriate anytime the nurse transfers the responsibility for the care of a client to another. This type of handoff reporting would allow the new nurse to ask questions to clarify care. A written handoff is appropriate when the client is being transferred to another care unit to another. It can also be used for change-of-shift report. A focus note is a type of documentation system, organized by data (D), action (A), and response (R). The Resident Assessment Instrument is a multidisciplinary tool used to track goal achievement of residents in long-term care settings.

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

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

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations? When reporting to a client's family member or significant other. When providing a change-of-shift report to a colleague. When documenting the care that was provided to a client whose condition recently deteriorated. When communicating a client's change in condition to the client's physician.

When communicating a client's change in condition to the client's physician. Explanation: SBAR communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members. SBAR is considered a framework for communication rather than a format for documentation.

A nurse is assessing a female client whose worsening sciatica has prompted her to seek care. Which client statement would the nurse most likely need to validate? "My mother died of breast cancer in her sixties." "I don't generally have problems with pain." "I feel very weak and tired right now." "I've had two cesarean deliveries."

don't generally have problems with pain." Explanation: The client's primary complaint (sciatica) is associated with pain; the nurse should validate the client's claim that she normally does not have pain issues. The statement about feeling weak and tired would lead the nurse to ask additional questions to determine the impact of pain on the client's ability to function. The statement about two cesarean deliveries and being generally happy and healthy would not require validation. The statement about her mother's death would not likely require validation