Chapter 9: Recording and Reporting

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry?

"Client reporting that her abdominal pain rated at 8/10."

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in her charting?

"If I make an error, I draw a single line through it and put my initials by it."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records."

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records?

"The clients' medical records are obstruction to research and education."

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose

The nurse is documenting an assessment that was completed at 9:30 pm. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

2130

You are a nurse taking care of a 49-year-old man who was admitted for acute pancreatitis. He was admitted yesterday and has been on IV fluids, has been kept NPO (nothing by mouth), and has been given IV pain medications since. During your nursing assessment he tells you that his pain is a 4/10 on the pain scale. It starts out in his epigastric area and radiates to his back. He also has been nauseous this morning. Your facility charts by exception. You finish filling out the flow sheet and have to write a progress note. Which of the following is an example of writing a progress note that represents charting by exception for this patient?

4/10 pain on pain scale, epigastric radiating to back; also complains of nausea

Which are examples of breaches of client confidentiality? Select all that apply.

A nurse discusses a client with a coworker in the elevator. A nurse shares her computer password with a relative of a client. A nurse updates the employer of a client regarding the client's return to work.

The client states, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today." His arms are folded across his chest. His brow is furrowed and he refuses to allow his morning vital sign measurements. Which entry should be included in the the nurse's charting? Select all that apply.

Arms are folded across his chest and brow is furrowed States, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today." Refuses to allow morning vital sign measurements

A nurse is taking care of a 15-year-old man with cystic fibrosis. The nurse is at the start of her shift and she goes in to the client's room to introduce herself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what he is supposed to be on, she notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation?

Attach a copy of the incident report to the chart.

A nurse is caring for a client with abdominal injury. What is a responsibility of the nurse?

Be aware of age-related differences.

Which method of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse?

Charting by exception

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note, in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?

Charting by exception (CBE)

A client with hemiplegia has been admitted to the health agency. The nurse who cares for the client has a fixed routine of cleaning, feeding, and administering medicines to the client. Which of the following should the nurse use to record these details?

Checklists

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?

Checklists

The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? (Select all that apply.)

Documentation must be kept of personnel who have accessed a client's record. Light boxes for examining X-rays with the client's name must be in private areas. Conversations about clients must take place in private places where they cannot be overheard.

A nurse is preparing an educational session on the purpose of documentation in medical records. Which topics should the nurse include in the education session? Select all that apply.

Facilitates quality Serves as a financial record Supports decision analysis Assists with clinical research

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document?

Intervention carried out

A nurse is preparing to document information about a client using the FOCUS system. Which information would the nurse record in the action section?

Interventions

The nurses on a hospital's high acuity unit have traditionally used walking rounds to provide change-of-shift report. This practice may violate the principles of HIPAA for what reason?

It is not normally possible to maintain confidentiality when discussing clients

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

Narrative notes

A health care agency has been asked to compensate a client as per a lawsuit filed for not following the Health Insurance Portability and Accountability Act (HIPAA) regulations. Which situation is a HIPAA violation?

Not informing a client in writing of the purpose of sharing his or her personal details

The nurses at a healthcare facility were informed of the change to organize the clients' records into source-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

What dual purpose does an audit serve?

Quality assurance and reimbursement

A nurse is preparing a seminar on the uses of documentation in client records. Which topics should the nurse include in the seminar? Select all that apply.

Quality improvement Research Decision Analysis Financial reimbursement

Which of the following is not typically found in the client care summary or kardex?

Respiratory assessment

During a client's hospitalization, he has developed shortness of breath, with edema. What action should the nurse take?

Revise the plan of care

SBAR

Situation, Background, Assessment, Recommendation

In what type of documentation does a nurse record narrative notes in a nursing section?

Source-oriented record

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?

Subjective data should be included when documenting.

SOAP method

Subjective data, Objective data, Assessment, Plan

Edema

Swelling

A client has requested a translator so that she can understand the questions that the nurse is asking her during the client interview. The nurse knows what is important when working with a client translator?

That translators may need additional explanations of medical terms

Which organization audits charts regularly?

The Joint Commission

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

A nurse has responded to a client's call light and the client has asked for assistance in transferring from the bed to the bathroom. However, the nurse has not previously been involved in the client's care and does not know the client's current activity orders. Where could the nurse most easily access this information?

The nursing Kardex

Which characteristic of a nurse's charting will assist most in the avoidance of errors?

Timeliness

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease, and their families. Providing this information is an example of:

a referral.

sclerosis

abnormal hardening of body tissue

The federally initiated goal of computer-based personal records would likely produce which of the following benefits? Select all that apply.

access to records outside of the client's home facility increased acccuracy of treatment for the client outside their home facility easier access to data for research greater accuracy and improved client care

Objective data

aspects of a patient's condition found through diagnostics, tests and examination

cystic fibrosis

defective gene causes a thick, buildup of mucus in the lungs, pancreas and other organs

What does the nurse recognize as the purpose of the electronic medical record? (Select all that apply.)

documenting continuity of care qualifying healthcare providers for government funds ensuring client safety facilitating health education and research

A nursing unit was recently audited. Which of the findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? (Select all that apply.)

documenting entries that are up to date and comprehensive recording the date and time of all entries using approved agency abbreviations

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

Subjective data

information provided by the client, such as a report of pain. Information from a patient's point of view

Charting by exception

is a shorthand documentation method that makes use of well-defined standards of practice

Besides being an instrument of continuous client care, the client's medical record also serves as a(an):

legal document

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining:

objectivity

hemiplegia

paralysis of one side of the body

A client was admitted to the Emergency Department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis?

public health department

Which information is the nurse expecting to find on the client's nursing care plan? (Select all that apply.)

the client's problem, goals, and nursing orders routine care, such as client's bath and mouth care the client's level of activity and current medical orders

Which information the nurse is expected to find on the nursing Kardex? (Select all that apply.)

the level of activity for the client the current medical order for the client the client's preparedness for an investigation

What situation would permit the nurse to disclose information without the client's approval?

the nurse suspecting that a client is being abused or neglected

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which people would be entitled to access of the client's records?

those directly involved in the client's care