Documentation and reporting Ch20 (exam 3 material)

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 nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse?

"I will have to review the policy that determines what procedure is in place for client access."

Which actions should the nurse take before making an entry in a client's record? Select all that apply. 1. Locating clients' files within an electronic health record system 2. Choosing the charting format that the nurse prefers 3. Checking that clients' names are not identified within the chart forms 4. Reviewing the agency's list of approved abbreviations 5. Identifying the form appropriate to be used for documenting

1,4,5

Which are appropriate actions for protecting clients' identities? Select all that apply. 1. Orient computer screens toward the public view. 2. Ensure that clients' names on charts are visible to the public. 3. Have conversations about clients in private places where they cannot be overheard. 4. Place light boxes for examining X-rays with the client's name in private areas. 5. Document all personnel who have accessed a client's record.

3,4,5

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate?

"Any information that can identify a person is considered a breach of client privacy."

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."

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?

"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

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?

SOAP charting

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? A. "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." B. "I am calling about the client in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." C. "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." D. "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."

A. "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information?

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

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

Exception

T/F? An example of a helpful and accurate nursing note is: "The patient appears to be resting more comfortably today than yesterday."

F

T/F? When receiving a verbal order, the registered professional nurse should ask for a "readback" from the medical provider.

F

Which statement is not true regarding a medication administration record(MAR)?

If the client declines the dose, the nurse does not have to document this on the MAR.

The nurses at a health care facility were informed of the change to organize the clients' records into problem-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 HCPs

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

Progress

At change of shift, the nurse is presenting information about a client to a colleague that is coming on shift. The nurse is performing what nursing action?

Reporting

The nurse is caring for a client who has an elevated temp. When calling the HCP, the nurse should use which communication tools to ensure that communication is clear and concise?

SBAR

T/F? All patient info written, saved on a compter, or spoken aloud is considered private or confidential.

T

T/F? Student nurses should never use their cellphone or conduct personal business on a computer in the clinical setting.

T

T/F? The purposes 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.

T

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment?

The client reports that on a scale of 0 to 10, the current pain is a 3.

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment?

The lower extremities

A nurse is arranging for home care for clients and reviews the medicare reimbursement requirements. Which client meets one of these requirements?

a client who is homebound and needs skilled nursing care

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 variance

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 (EHRs), allow data to be distributed among many caregivers in a standardized format.

electronic

The _____________ record is a form used to record specific patient variables such as a pulse, RR, BP readings, bodt temperature, weight, fluid intake and output, BM and other patient characteristics.

graphic

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 declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?

those directly involved in the client's care