Documentation and reporting

Coronary artery bypass graft is abbreviated CABG. It does not identify nutritional needs, decrease liver inflammation, or increase intestinal motility pg524

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? - A coronary artery bypass graft will benefit your heart. - The CABG procedure will help identify nutritional needs. - A complete ablation of the biliary growth will decrease liver inflammation. - The CABG procedure will help increase intestinal motility and prevent constipation.

Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others. pg543

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 - a consultation - conferring - reporting

Point-of-care documentation takes place as care occurs, thus enhancing accuracy. Today many facilities incorporate technology that is mobile and can be used immediately at the client's bedside for point-of-care documentation. The nurse should not delegate documentation, nor should it be left to the end of a shift. Documentation should be performed more than once every 6 hours. pg532

A nurse has begun a new role on a high acuity unit where clients' health status often change rapidly. What practice should the nurse adopt to maximize the accuracy of documentation? - Chart at least every 6 hours - Use point-of-care documentation whenever possible - Summarizes client care thoroughly at the end of the shift and complete documentation for the shift - Delegate charting appropriately to unlicensed assistive personnel

This scenario reflects a variance in care. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client pg542

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? - A never event - A variance - An audit - A sentinel event

Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team. pg542

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? - identifying risks and ensuring future safety for clients - gauging the nurse's professional performance over time - protecting the nurse and the hospital from litigation - following up the incident with other members of the care team

HIPAA affords clients the right to see and copy their health records, update their health records, and get a list of disclosures that a health care institution has made for the purposes of treatment, payment, and health care operations. Clients 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. pg522

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

Quality process review recognizes that ____ is the primary source of evidence used to continuously measure performance outcomes against predetermined standards

Documentation

Computer based records or _____ health records allow data to be distributed among many caregivers in a standardized format

Electronic

An example of a helpful and accurate nursing notes is "the patient appears to be resting more comfortably today than yesterday"

False

When receiving a verbal order, the registered professional nurse should ask for a read back from the medical provider.

False

The _____ record is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.

Graphic

Charting by exception (CBE) 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. pg534

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? - It documents assessments on separate forms. - It records progress under problems, intervention, and evaluation. - It provides and refers to a client's problem by a number. - It provides quick access to abnormal findings.

In a source-oriented record, nurses include information to inform caregivers of achievement toward patient goals in a narrative format called a _____ note

Progress

The statement uses approved abbreviations for complains of (c/o) and headache (H/A). Therefore the statement indicates that the client is complaining of a severe headache this morning. The abbreviation c/o stands for complains of, not coughing. The abbreviation H/A stands for headache, not heart attack or heartburn pg524

The following statement is documented in a client's health record: "Client c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? - The client reports waking up this morning with a severe headache. - The client has symptoms in the morning associated with a heart attack. - The client is coughing and experiencing severe heartburn in the morning. - The client has a history of severe complaints in the morning.

The nurse should use SBAR (situation, background, assessment, recommendation) when communicating with the health care provider. SOAP and PIE are nursing notes in the medical record, and MAR is medication administration record. pg539

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? - SBAR - SOAP - PIE - MAR

Objective data, such as the measurable urine output, are collected by the nurse. Subjective data, such as feeling pain, itchiness, or fatigue, are reported by the client. pg534

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? - pain rating of 4 on a scale of 0-10 - describes wound as itchy - urine output 100 ml - concerned with feeling tired

Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. Because the child is a minor, it is the parents' right to view the client's record. Therefore, the statements about the health care provider not giving the parents access to review the records and asking if the parents are questioning the care of their child are incorrect pg522

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse? - I will arrange access for you to review the record after you put your request in writing. - No, the health care provider will not give you access to review the records. - Are you questioning the care of your child? - Only the client has the right to review the health care records

All patient information written, saved on a computer, or spoken aloud is considered private or confidential

True

Student nurses should never use their cellphone or conduct personal business on a computer in the clinical setting

True

The purpose of patient records include reimbursement, communication, diagnostic, and therapeutic orders, research, decision analysis, quality process and performance improvement, education, care planning, and providing a legal source of documentation

True

A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today pg521

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: - factual statement. - interpretation of data. - important information. - relevant data

In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart pg528

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: - limiting abbreviations to those approved for use by the institution. - using only abbreviations whose meaning is self-evident to an educated health professional. - ensuring that abbreviations are understandable to clients who may seek access to their health records. - using only those abbreviations that are defined in full at another location in the client's chart.

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 pg534

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 nurse implementing? - FOCUS charting - SOAP charting - PIE charting - narrative charting

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. pg522

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

Providing information over the phone to a family member without knowing whether or not the client wants that family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach of confidentiality, but providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information pg520

Which example may illustrate a breach of confidentiality and security of client information? - The nurse provides information over the phone to the client's family member who lives in a neighboring state. - The nurse provides information to a professional caregiver involved in the care of the client. - The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. - The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell.

The clients' medical records are good sources of data for research and education, and, therefore, it is incorrect to say that they are an obstruction. The other statements do not need correction. pg528

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 provide data for legal evidence. - I can share the clients' medical records with the health care team. - The clients' medical records are an obstruction to research and education. - The clients' health records should be used to promote reimbursement from insurance companies

Any identifying information regarding the client's demographics such as name, age, gender, diagnosis, and so on should be communicated to the oncoming nurse caring for the client. Any current orders or orders that have not been completed during the shift should be communicated as well. The oncoming nurse should be informed of any occurrences with the client that have been out of the norm and what actions, if any, were taken. Information about what the client watched for entertainment is not of relevance and should be eliminated from the report, as well as what time the nurse will be working next. pg533

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply. - what the client watched on television during the shift - what time the nurse will return for the next shift - any abnormal occurrences with the client during the shift - identifying demographics, including diagnosis - current orders

Charting by _____ is a shorthand documentation method in which only deviations from well defined standards of practice are documented in narrative notes

exception