Documentation and Reporting

What PACE format stand for?

-Patient/problem -assessment/actions -continuing/changes -Evaluation

What are disadvantages of charting by exception? Select all that apply -Pertinent information could be omitted because it is not considered significant -It is difficult to capture the skilled judgement of nurses -It is very cumbersome and time-consuming to use -It can lead to errors because nurses may conclude that care has been done when it has not. -It results in repeat work when interventions of assessment findings are documented in multiple places

-Pertinent information could be omitted because it is not considered significant -It is difficult to capture the skilled judgement of nurses -It can lead to errors because nurses may conclude that care has been done when it has not.

What are disadvantages of charting by exception? Select all that apply. -Pertinent information could be omitted because it is not considered significant. -It is difficult to capture the skilled judgment of nurses. -It is very cumbersome and time-consuming to use. -It can lead to errors because nurses may conclude that care has been done when it has not. -It results in repeat work when interventions or assessment findings are documented in multiple places. -There is virtually no opportunity for repeat work or duplicate documentation.

-Pertinent information could be omitted because it is not considered significant. -It is difficult to capture the skilled judgment of nurses -It can lead to errors because nurses may conclude that care has been done when it has not.

The nurse contacts the primary health-care provider about a change in a client's status. The primary health-care provider in turn gives the nurse orders over the telephone. What are the nurse's responsibilities related to accepting these orders? Select all that apply. -Pronouncing numerical digits separately -Spelling out any unfamiliar names or words -Repeating what was stated before hanging up -Having a second nurse listen to verify the orders -Ensuring the orders are countersigned within 48 hours -Obtaining the orders and implementing them immediately

-Pronouncing numerical digits separately -Spelling out any unfamiliar names or words -Repeating what was stated before hanging up -Having a second nurse listen to verify the orders

The nurse contacts the primary health-care provider about a change in a client's status. The primary health-care provider in turn gives the nurse orders over the telephone. What are the nurse's responsibilities related to accepting these orders? Select all that apply. -Pronouncing numerical digits separately -spelling out any unfamiliar names or words -repeating what was stated before hang up - having a second nurse listen to verify the orders -ensure the orders are countersigned within 48 hours -obtaining the orders and implementing them immediately

-Pronouncing numerical digits separately -spelling out any unfamiliar names or words -repeating what was stated before hang up - having a second nurse listen to verify the orders

Which chart entry would be part of SOAP documentation? Select all that apply -The client complains of pain at the incision site -Redness and edema is noted at the incision site. -the client was discharged home in stable condition -the physician was notified about sings of infection at the incision site. -The physician performed rounds, visiting client in the morning

-The client complains of pain at the incision site -Redness and edema is noted at the incision site. -the physician was notified about sings of infection at the incision site.

Which are benefits of large systems using electronic health records (EHRs)? Select all that apply. -To develop better disease treatment methods -To understand disease causes and progression -To determine outcomes for various populations -To support evidence-based practice and research -To provide standardized terminology in documentation

-To develop better disease treatment methods -To understand disease causes and progression -To determine outcomes for various populations

Which are benefits of large systems using electronic health records (EHRs)? Select all that apply. -To develop better disease treatment methods -To understand disease causes and progression -To determine outcomes for various populations -To support evidence-based practice and research -To provide standardized terminology in documentation

-To develop better disease treatment methods -To understand disease causes and progression -To determine outcomes for various populations

The nurse is caring for a client who fell while trying to get out of bed without assistance. As the nurse is completing the incident report, what should the nurse include in the documentation? Select all that apply. -What happened in an objective manner -The incident in the medical record -Actual statements from the client -The date, time, and location of the incident -Who is to blame for the incident occurring

-What happened in an objective manner -Actual statements from the client -The date, time, and location of the incident

The nurse is caring for a client who fell while trying to get out of bed without assistance. As the nurse is completing the incident report, what should the nurse include in the documentation? Select all that apply. -What happened in an objective manner -The incident in the medical record -Actual statements from the client -The date, time, and location of the incident -Who is to blame for the incident occurring

-What happened in an objective manner -Actual statements from the client -The date, time, and location of the incident-

paper record disadvantages

-access may be delayed -retrieving information may be slow -documentation is time-consuming -high risk for patient care error -storage is expensive

Types of Handoff Reports

-bedside report -face-to-face oral report -Audio- recorded report

paper records advantages

-care providers are comfortable -do not require large databases -no downtime for system changes -relatively inexpensive

the purpose of documentation

-communication about the client's status and care -continuity of care -Quality improvement -Planning and evaluation of patient outcomes -legal record -professional standards of care -reimbursement and utilization

EHR advantages

-enhanced communication and collaboration -improved access to information -time savings -improve quality of care -information is private and safe

EHR disadvantages

-expense -downtime -difficulties associated with change -lack of integration

how do I question a prescription?

-follow organization policy for clarifying -if a prescription is written illegibly on paper or is entered into the EHR missing certain details -If, after contact, the provider leaves the prescription as is and you still don't feel comfortable

problem oriented medical record

A record organized according to a patient's specific health problems. Four major parts - (1) Database, (2) Problem list, (3) The initial plan, (4) Progress Notes

A nurse has concerns that an order written on a client is not appropriate. She contacts the physician, who insists the order is correct. The nurse still has reservations about carrying out the order. What is the appropriate course of action? A. Inform her supervisor about her concerns regarding the order B. Carry out the order, as it is part of the prescribed plan of care C. Refuse to carry out the order and document the reason for refusing it in the medical record d. Discuss it with the client and inform the client of his or her right to refuse treatment

A. Inform her supervisor about her concerns regarding the order

Which type of communication would the nurse be using when giving a bedside change of shift report to another nurse? A. Oral communication B. Written communication C. Electronic communication D. Nonverbal communication

A. Oral communication

Which type of organization of health records involves members of each discipline recording their findings in a separate section of the chart? A. Source-oriented B. Problem-oriented C. Charting by exception D. Improvement-oriented

A. Source-oriented Rationale: In source-oriented record systems, members of each discipline record their findings in separate sections of the chart.

Which represents correct documentation in the medical record of an initial nursing assessment of a client admitted with pneumonia? A. The client appears short of breath, with wheezing in all lung fields B. The client is admitted with pneumonia and the nurse will watch for respiratory symptoms C. Respiratory treatments are given as ordered every 4 hours D. The client reports improved breathing after breathing treatments given

A. The client appears short of breath, with wheezing in all lung fields

Which represents correct documentation in the medical record of an initial nursing assessment of a client admitted with pneumonia? A. The client appears short of breath, with wheezing in all lung fields. B. The client is admitted with pneumonia and the nurse will watch for respiratory symptoms. C. Respiratory treatments are given as ordered every 4 hours. D. The client reports improved breathing after breathing treatments given.

A. The client appears short of breath, with wheezing in all lung fields. Rationale: Documentation of a nursing assessment includes signs and symptoms and an indication of any actual or perceived problems.

Which type of organization of health records involves members of each discipline recording their findings in a separate section of the chart? A. Source-oriented B. Problem-oriented C. Charting by exception D. Imrovement-oriented

A. source-oriented Rationale: In source-oriented record systems, members of each discipline record their finding in separate sections of the chart.

The nurse is caring for a client following a surgical procedure. The health-care provider's orders include vital signs every 15 minutes for one hour, every 30 minutes for two hours, then every hour for four hours. Which type of document would best serve this nurse? A. Narrative document B. Graphic Chart C. Charting by exception D. Admission assessment

B. Graphic Chart Rationale: A graphic chart allows the nurse to make multiple entries and graph trends in vital signs. This could help detect problems early.

The nurse is caring for a client following a surgical procedure. The health-care provider's orders include vital signs every 15 minutes for one hour, every 30 minutes for two hours, then every hour for four hours. Which type of document would best serve this nurse? A. Narrative document B. Graphic chart C. Charting by exception D. Admission assessment

B. Graphic chart Rationale: A graphic chart allows the nurse to make multiple entries and graph trends in vital signs. This could help detect problems early.

The nurse uses the SOAP format for documentation and types in a client's medical record, "The left coccyx wound is reddened and measures 1 cm x 2 cm x 0.2 cm and is without drainage." Which aspect of the SOAP format is this considered? A. Subjective B. Objective C. Assessment D. Plan

B. Objective

The nurse uses the SOAP format for documentation and types in a client's medical record, "The left coccyx wound is reddened and measures 1 cm x 2 cm x 0.2 cm and is without drainage." Which aspect of the SOAP format is this considered? A. Subjective B. Objective C. Assessment D. Plan

B. Objective Rationale: Objective data is factual, measurable clinical findings such as vital signs, test results, and quality of breath sounds.

Which is a method of providing a complete communication during a hand-off report? A. SOAP B. SBAR C. CPOE D. MAR

B. SBAR

Which elements of documentation can be delegated to unlicensed assistive personnel? A. Documentation of initial assessment B. Documentation of the intensity and nature of the client's pain C. Documentation of vital signs and activities of daily living D. Documentation of medication administration

C. Documentation of vital signs and activities of daily living

What should be considered when using abbreviations in nursing documentation? A. It is acceptable to use common abbreviations in all documentation B. Abbreviation should never be used in documentation C. Each facility should have a list of approved abbreviations, and those that should not be used. D. Every medical record should have a reference as an addendum to identify the meaning of any abbreviations

C. Each facility should have a list of approved abbreviations, and those that should not be used

What should be considered when using abbreviations in nursing documentation? A. It is acceptable to use common abbreviations in all documentation. B. Abbreviations should never be used in documentation. C. Each facility should have a list of approved abbreviations, and those that should not be used. D. Every medical record should have a reference as an addendum to identify the meaning of any abbreviations.

C. Each facility should have a list of approved abbreviations, and those that should not be used.

How often must a long-term care facility complete the Minimum Data Set for Resident Assessment and Care Screening (MDS) after initial admission? A. Every month B. Every 2 months C. Every 3 months D. Every 6 months

C. Every 3 months

The nurse begins a shift, performs a client assessment, and then proceeds to prepare to administer medications. At what point should the nurse document the assessment? A. At the end of shift B. After administering medications C. Immediately after the assessment D. At the same time as all other documentation

C. Immediately after the assessment

The nurse begins a shift, performs a client assessment, and then proceeds to prepare to administer medications. At what point should the nurse document the assessment? A. At the end of the shift B. After administering medications C. Immediately after the assessment D. At the same time as all other documentation

C. Immediately after the assessment Rationale: The nurse should immediately document the assessment once it is finished. This ensures accuracy and communicates findings to other providers.

The nurse is caring for a client admitted with abdominal pain, nausea, and a bowel obstruction. The client states, "I feel nauseous, and I am going to vomit." The nurse administers an antiemetic after the client vomits 200 mL of greenish-brown fluid. In the SOAPIE documentation system, under which aspect would the administration of the antiemetic be documented? A. Subjective data B. Assessment findings C. Interventions provided D. Evaluation of client

C. Interventions provided

The nurse is caring for a client admitted with abdominal pain, nausea, and a bowel obstruction. The client states, "I feel nauseous, and I am going to vomit." The nurse administers an antiemetic after the client vomits 200 mL of greenish-brown fluid. In the SOAPIE documentation system, under which aspect would the administration of the antiemetic be documented? A. Subjective data B. Assessment findings C. Interventions provided D. Evaluation of client

C. Interventions provided Rationale: The nurse would document the administration of the antiemetic under interventions provided.

What is the significance of using standardized reporting formats? A. It is required by the Joint Commission B. It is the policy of most facilities C. Many serious errors occur as a result of miscommunication between caregivers. D. Physicians expect this practice among nurses.

C. Many serious errors occur as a result of miscommunication between caregivers.

If an error is made in nursing documentation, what should the nurse do? A. The error must remain in the record because health records cannot be altered B. The error must be deleted C. The entry is noted as being an error, and an addendum with correct information is added D. The medical record must be discarded and a new one started

C. The entry is noted as being an error, and an addendum with correct information is added

Which statement describes the purpose of utilization review as related to documentation in the medical record? A. To determine effectiveness of care B. To evaluate continuity of care provided C. To verify medical treatments are necessary D. To determine the nurse is providing appropriate care

C. To verify medical treatments are necessary

Which statement describes the purpose of utilization review as related to documentation in the medical record? A. To determine effectiveness of care B. To evaluate continuity of care provided C. To verify medical treatments are necessary D. To determine the nurse is providing appropriate care

C. To verify medical treatments are necessary

Which characteristic of the electronic health record (EHR) helps prevent medication errors? A. Facilitating remote access of the EHR for health-care providers B. Allowing multiple health-care providers access to the EHR at once C. Providing text notifications of when medications are due D Preventing medications from being administered to clients with allergies

D Preventing medications from being administered to clients with allergies Rationale: The safeguards in the EHR would prevent a pharmacist from dispensing a medication to which the client has an allergy.

Which is a major disadvantage of the electronic health record (EHR)? A. Inability to guarantee client privacy B. Information is safe and cannot be lost C. Lack of ability to analyze data in the record D. Incapability to integrate records from multiple locations

D. Incapability to integrate records from multiple locations Rationale: A disadvantage of the EHR is that client information from one health-care provider does not always merge with that of a different health-care provider. This can make continuity of care between different providers difficult.

The nurse is preparing to administer an insulin injection to a client with an elevated blood glucose level. What should the nurse check in the electronic medication administration record prior to giving the dose? A. Age B. Weight C. When the client last ate D. Location of last injection

D. Location of last injection

The nurse is preparing to administer an insulin injection to a client with an elevated blood glucose level. What should the nurse check in the electronic medication administration record prior to giving the dose? A. Age B. Weight C. When the client last ate D. Location of last injection Rationale: The nurse should check the electronic medication administration record to determine where the last injection was administered. This allows the nurse to rotate sites and prevent injury from injecting the client in the same place.

D. Location of last injection Rationale: The nurse should check the electronic medication administration record to determine where the last injection was administered. This allows the nurse to rotate sites and prevent injury from injecting the client in the same place.

Which characteristic of the electronic health record (EHR) helps prevent medication errors? A. Facilitating remote access of the EHR for health-care providers B. Allowing multiple health-care providers access to the EHR at once C. Providing text notifications of when medications are due D. Preventing medications from being administered to clients with allergies

D. Preventing medications from being administered to clients with allergies Rationale: The safeguards in the EHR would prevent a pharmacist from dispensing a medication to which the client has an allergy.

The nurse is documenting client care in a medical record. The facility uses a problem-oriented record system. In which area would the nurse document the medications he or she administers? A. The database B. The problem list C. The plan of care D. The progress notes

D. The progress notes

The nurse is documenting client care in a medical record. The facility uses a problem-oriented record system. In which area would the nurse document the medications he or she administers? A. the database B. the problem list C. the plan of car D. the progress notes

D. the progress notes

How often must a long-term care facility complete the Minimum Data Set for Resident Assessment and Care Screening (MDS) after initial admission? A. Every month B. Every 2 month C. Every 3 months D. Every 6 months

Every 3 months Rational: Federal laws mandated that the DS be updated every 3 months to document client status

Transfer report

Given when a patient is transferred from unit to unit or from facility to facility.

What do IPASS format stand for?

Illness severity, patient summary, action list, situation awareness and contingency plan, synthesis by receiver

The nurse is preparing to administer morning medications to a client. As the nurse reviews the electronic medication administration record, which medications require an assessment prior to administration? Select all that apply. -Insulin -Digoxin -Antihistamine -Bronchodilator -Antihypertensive -Chemotherapy drugs

Insulin -Digoxin -Antihypertensive -Chemotherapy drugs

PIE format

P -- Problem (nursing diagnosis) I -- Intervention (nursing interventions performed for each problem) E -- Evaluation (patient's response to nursing interventions)

Problem-Intervention-Evaluation (PIE)

Problem: Uses data from your assessment to identify appropriate diagnosis Intervention: Document the nursing actions you take for each nursing diagnosis Evaluation: Document the patient's response to interventions and treatments

What SBAR stand for?

Situation, Background, Assessment, Recommendation

What is the purpose of an occurrence report?

a formal record of an unusual occurrence or accident. This is an agency report and is not part of the patient's chart. This form are used to track problems and identify areas for quality improvement. The goal of documentation is to analyze the information in the occurrence report and identify strategies to prevent any future occurrences

AKA

above knee amputation

documentation

act of recording patient status and care

amb

ambulate

ad lib

as desired

BRP

bathroom privileges

BR

bed rest

BSC

bedside commode

electronic documentation system

contain both source-oriented and problem-oriented records.

CCU

coronary care unit, critical care unit

What does DAR stand for?

data, action, response

D&C

dilation and curettage

Home Care Documentation

documentation must include (a) certification of homebound status, (b) ongoing assessment of the need for skilled care, (c) use of the OASIS data set, and (d) a monthly summary describing the patient's status and ongoing needs. The patient's provider signs this form, and this is submitted for reimbursement.

source-oriented record

documentation system in which each health care group records data on its own separate form

EBL

estimated blood loss

Identify four events in which you will need to complete an occurrence report.

falls or other patient injury, loss of patient belongs, theft or any criminal activity, or administration of the wrong medicine

Which charting uses DAR format?

focus charting

HA

headache

Isol

isolation

LMP

last menstrual period

os

mouth

OB

obstetrics

Which type of communication would the nurse be using when giving a bedside change of shift report to another nurse? A. oral communication B. written communication C. electronic communication D. Nonverbal communication

oral communication

PPBS

postprandial blood sugar

R/O

rule out

Charting by exception (CBE)

shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes

SSE

soap suds enema

SOAP format

subjective data, objective data, assessment, plan

Long-term Care documentation

t include (a) a comprehensive assessment using the Minimum Data Set for Resident Assessment and Care Screening (MDS) within 14 days of admission and updates at specified intervals with any significant change in client condition, (b) a report of any changes in a client's condition to the primary care provider and the client's family, and (c) a summary by an LVN/LPN or RN either weekly for clients receiving skilled services or every 2 weeks for clients receiving intermediate care services.

TPR

temperature, pulse, respiration

Oral reporting

to maintain continuity of care, engage in professional communications, build team relationship, and collaborate to improve client care

Narrative progress notes format

used with written source-oriented and problem-oriented charts

Focus charting

uses assessment data to evaluate client cae concerns, problems, or strengths

The nurse is admitting a new client to an acute rehabilitation facility and is completing the paperwork. The client is getting frustrated with the amount of time it is taking. What information can the nurse provide about the admission assessment to help the client understand the process? Select all that apply. -"Everyone admitted to the facility must go through this. We will be finished soon." -"We use this information to determine how you progress as you go through therapy." -"This information allows us to identify any needs you will have when you are discharged." -"It provides all health-care providers necessary information including allergies, needs, and abilities." -"The government requires all acute rehabilitation facilities to collect this information."

-"We use this information to determine how you progress as you go through therapy." -"This information allows us to identify any needs you will have when you are discharged." -"It provides all health-care providers necessary information including allergies, needs, and abilities."

Which are examples of appropriate medication orders? Select all that apply. -Lasix by mouth twice daily -Aspirin 325mg by mouth every morning -Tylenol 500 mg prn -Rocephin 200 mg IV Q6h -Ibuprofen 200 mg q4h prn fever or mild pain

-Aspirin 325mg by mouth every morning -Rocephin 200 mg IV Q6h -Ibuprofen 200 mg q4h prn fever or mild pain

Which information should always be included in a report in which a client is transferred from one unit to another? Select all that apply. -Client's name, age, and diagnosis -Last set of vital signs -History of appendectomy 5 year prior -Allergy to penicillin -Tubes, lines, or IV therapy

-Client's name, age, and diagnosis -Last set of vital signs -Tube, lines, or IV therapy

Identify the purposes of the client health record.

-Communication among health professionals and continuity of care • Legal documentation • Education of health professionals • Legislative requirements • Quality improvement • Professional standards of care upheld • Identification of the cost of care for reimbursement and utilization review • Health-related research • Record of care provided over time

Which are ways health providers use documentation to provide quality care? Select all that apply. -Communication tool -Continuity of Care -Provide shift report -Communicate with family members -Legal record

-Communication tool -Continuity of Care -Legal record

Which are ways health providers use documentation to provide quality care? Select all that apply. -Communication tool -Continuity of care -Provide shift report -Communicate with family members -Legal record

-Communication tool -Continuity of care -Legal record

If a written order is confusing or unclear, what action should the nurse take? A. Try to use clinical judgement to decide what the order should state B. Contact the provider for clarification C. Refuse to perform the order D. Document that the order was unclear

-Contact the provider for clarification

What does FACT system charting?

-Flowsheets -Assessment -Concise, integrated progress note and flowsheets documenting -Timely entries

A home health nurse receives a referral to provide care to a client in his or her home. According to the Center for Medicare and Medicaid Services, what should the nurse document in the client's medical record? Select all that apply. -Homebound status of the client -Ongoing need for skilled services -Presence of family support in home -Ability to afford and pay for services -Completion of the minimum data set

-Homebound status of the client -Ongoing need for skilled services

A home health nurse receives a referral to provide care to a client in his or her home. According to the Center for Medicare and Medicaid Services, what should the nurse document in the client's medical record? Select all that apply. -Homebound status of the client -Ongoing need for skilled services -Presence of family support in home -Ability to afford and pay for services -Completion of the minimum data set

-Homebound status of the client -Ongoing need for skilled services -Completion of the minimum data set

The nurse is preparing to administer morning medications to a client. As the nurse reviews the electronic medication administration record, which medications require an assessment prior to administration? Select all that apply. -Insulin -Digoxin -Antihistamine -Bronchodilator -Antihypertensive -Chemotherapy drugs

-Insulin -Digoxin -Antihypertensive -Chemotherapy drugs

Which are functions of a client's medical record? Select all that apply. -Legal record -Communication -Continuity of Care -Quality improvement -Primary health-care provider evaluation -Development of standardized method of charting

-Legal record -Communication -Continuity of Care -Quality improvement

Which are functions of a client's medical record? Select all that apply. -Legal record -communication -Continuity of care -Quality improvement -primary health-care provider evaluation - development of standardized method of charting

-Legal record -communication -Continuity of care -Quality improvement

A client reports a pain rating of 9 on a scale of 1 to 10. The nurse administers an intravenous narcotic analgesic to the client. What will the nurse include when documenting this task? Select all that apply. -Location and characteristics of the pain -Client's pain level 30 to 60 minutes after the medication is given -Administration of the intravenous narcotic analgesic medication -Family's interpretation of the client's symptoms and behaviors -Nurse's opinion of client's pain level and activities prior to pain medication

-Location and characteristics of the pain -Client's pain level 30 to 60 minutes after the medication is given -Administration of the intravenous narcotic analgesic medication

At which points of client care must the nurse complete a discharge summary? Select all that apply. -Move to an acute rehabilitation unit -Sent down for an endoscopic procedure -Transferred to a long-term skilled facility -Allowed to leave the hospital and go home -Expired in the health-care facility

-Move to an acute rehabilitation unit -Transferred to a long-term skilled facility -Allowed to leave the hospital and go home

At which points of client care must the nurse complete a discharge summary? Select all that apply. -Moved to an acute rehabilitation unit -Sent down for an endoscopic procedure -Transferred to a long-term skilled facility -Allowed to leave the hospital and go home -Expired in the health-care facility

-Moved to an acute rehabilitation unit -Transferred to a long-term skilled facility -Allowed to leave the hospital and go home