Jensen - Ch. 16

Which is the proper way to document midnight in a client's record?

0000

Which charting format permits documentation on any significant topic, not just client problems?

FOCUS

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions

Which abbreviation is correct for use in documentation?

PO

A health care facility plans to evaluate and revise the plan of care for a client based on the client's health care records. The physician, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details?

SOAP charting

A nurse is planning to document assessment findings for an assigned client on a graphic record. Which findings would be appropriate to document on this form? Select all that apply.

Temperature Bowel movements Weight Blood pressure

A nurse is preparing to document care provided to a client. What would be most appropriate for the nurse to do to ensure that the documentation is concise?

Use phrases in narratives.

What does the nurse recognize as purposes of the electronic health record? Select all that apply.

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

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

have the right to copy their health records.

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

"According to HIPAA legislation, you have a right to request changes to inaccurate information."

The nurse is taking verbal medication prescriptions from the health care provider by hand to be documented in the clients eMAR for administration of medication. How should the nurse correctly document this information?

0800-Amoxicillin 250mg PO with water. J. Doe, RN.

At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use?

2015

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?"

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's morning assessment of an older adult client has revealed some anomalies. The nurse should document the client's abnormal heart rate as:

"115 beats per minute"

Which data entry follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

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."

Which is true of collaborative pathways?

Are also called critical pathways or care maps

Which is a drawback to the type of documentation known as charting by exception?

Issues related to high-quality care should a negligence claim arise

Which statement regarding FOCUS charting is most accurate?

The charting focuses on client strengths, problems, or needs.

What is the primary purpose of FOCUS charting?

To concentrate on the client and client concerns in documentation

Which strategy would provide the most effective form of change of shift report?

Utilizing a reporting form and allowing time for any questions.

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

a flow sheet

A nurse organizes client data using the SOAP format. Which information would be recorded under "S" of this acronym?

client reports of pain

A nurse documents hypertension in a woman who is 5 months pregnant and then writes a narrative describing the situation. This type of abnormal status can be seen immediately with narrative easily retrieved in what documentation format?

Charting by exception

The nurse is caring for a client in the intensive care unit who must be administered multiple medications. The client is often unresponsive and cannot offer information during assessment. When administering the medication, which step by the nurse is most important to avoid confusion and ensure safety?

Compare the client's wristband to the eMAR and EHR information if the client is unresponsive, then verify the medication has the same identifying information.

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

intervention carried out

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edmatous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"?

FOCUS

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.

A health care provider suggests that the nurse use the computer terminal that is available at the point of care or at the client's bedside. What is the probable reason for this suggestion?

The client has had a sudden change in status needing immediate attention.

A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy?

Use minimum disclosure policy to release the information.

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)

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 client will be transferred from the cardiovascular intensive care unit to the telemetry unit for continued care. Which documentation correctly demonstrates how the nurse would prepare information to be conveyed to the receiving nurse during a verbal handoff report?

Mr. Alfred Jones, MR#12345, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes.

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider?

The nurse can accept verbal orders to provide immediate care and record once the client is stable.

A nurse is giving the change-of-shift report on a client who has just returned from surgery. What client information should the nurse include in the report? Select all that apply.

name of the client intake and output prior to surgery client discharge teaching needs current vital signs

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 should the nurse use to record these details?

checklists

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 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.

In SBAR, what does R stand for?

Recommendations

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate?

"The benefit of CBE is less time needed on computer charting."

The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development?

"The care plan is required for every client by The Joint Commission."

Which components should the nurse include when documenting a critical pathway? Select all that apply.

Care plan Expected outcomes Timeline

What is the primary purpose of the client record?

Communication

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

Incident report

A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)?

Minimum data set

Which documentation by the nurse best supports the PIE charting system?

Vomiting 250 mL undigested food, antiemetic given, no further vomiting

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 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

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which clinical situation?

when communicating a client's change in condition to the client's physician

A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality?

writing the client's name on the student care plan

A nurse in the intensive care unit has just reported for duty. A client is being transferred to the medical floor after change of shift. Which action would the nurse take to ensure maximum efficiency of change-of-shift or transfer reports?

Utilize the electronic medical record while providing report to the receiving nurse.

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them.

"I don't feel well. I've been urinating often, and it burns when I urinate." Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. Fever, possible urinary tract infection Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

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 an obstruction to research and education."

A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which is an example of a written form of communication?

checklist

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which drawback?

vulnerability to legal liability since nurse's safe, routine care is not recorded

The following information appears on a client's medical record: Client states, "I have a fair amount of pain in my belly near my incision"; heart rate 88; respirations 22; abdomen distended; incision clean and dry; last medicated for pain 5 hours ago; abdominal pain secondary to surgery 2 days ago; reassess pain level using pain rating scale in 30 minutes; administer oxycodone 5 mg as ordered; monitor vital signs every 4 hours; client lying on side with legs drawn up and massaging abdominal area. When documenting this information using the SOAP method, which part would the nurse document as "S"?

"I have a fair amount of pain in my belly near my incision"

A nurse is assisting during a medical emergency on the medical unit. Which action by the nurse when documenting entries in a client's health care record would be the most accurate?

Making entries in chronological order

A nurse is documenting care for an older adult client who is recovering from a mild stroke. Which documentation entries follow the recommended guidelines for communicating and documenting client information? Select all that apply.

The client rates pain as 2 compared to a 7 yesterday. Vital signs returned to normal. Radial pulse 72, strong and regular

Which information should the nurse include in a client's plan of care? Select all that apply.

The client's problems, goals, and nursing orders Routine care, such as the client's bath and mouth care The client's level of activity and current medical orders

The nurse is assessing a client's postoperative pain. Which statement demonstrates accurate documentation of objective pain assessment?

"Client rates pain 4 on a scale of 0 to 10."

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication?

"I think the client would benefit from intravenous furosemide."

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply.

"I will write, print, or type information legibly." "I will use only agency-approved abbreviations." "I will draw a straight line through any blank space."

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best?

"The UAP is able to log in and enter the information so all members of the health care team can see it."

Which note includes all elements of a SOAP note?

Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client?

0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.

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

A nurse discusses information about a client with a coworker in the elevator. A nurse shares his or her computer password with another nurse who was unable to log in to the system. A nurse updates the employer of a client regarding the client's date of return to work.

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

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?

Accurately documenting client care on the client record

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."

Which is the primary purpose of client records?

Communication

When documenting client care, which principles should the nurse strive for? Select all that apply.

Confidentiality Accuracy Objectivity Timeliness

Which are appropriate actions for protecting clients' identities? Select all that apply.

Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.

The nurse documents that a client does not have pain prior to the administration of pain medication. The client, however, requested medication for increasing postsurgical pain. What is the appropriate action to correct the pain assessment documented in the client's paper medical record?

Place one line through the entry and initial it.

A nursing unit was recently audited. Which 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

A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next?

Individualize it to the specific client.

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 provides quick access to abnormal findings.

What is the primary purpose of an incident report?

Means of identifying risks

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.

Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records

Which actions should the nurse take before making an entry in a client's record? Select all that apply.

Reviewing the agency's list of approved abbreviations Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting

A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply.

S: The nurse handling the transfer describes the client situation to the new nurse. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse gives recommendations for future care to the new nurse in charge.

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

The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply.

Showing the provider the trends from baseline to present in blood pressure Informing the provider of the client's present heart rate of 116 beats/min Faxing the results of blood chemistry levels to the provider's office

The nurse charted the administration of preparation for a colonoscopy in the AM in the progress notes of the client's paper chart, pictured above. Which correct documentation guidelines did the nurse follow? Select all that apply.

Sign every entry Document in chronological order Identify the day and time for each entry Acknowledge the client's response to the medication

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation?

Source-oriented

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?

Submitting a written notice to all clients identifying the uses and disclosures of their health information

A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology?

Telemedicine and mobile technology

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.

The following statement is documented in a client's health record: "Patient 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.

Which is not a purpose of the client care record?

To serve as a contract with the client

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 can only retrieve patient records but cannot view the details.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

The nurse has paged a client's primary care physician in response to the client's low blood pressure reading. When returning the nurse's page, the physician has asked the nurse to temporarily hold the client's scheduled antihypertensive and diuretic medications. How should the nurse ensure correct documentation of this telephone order?

Write "T.O." after the order and write out the physician's name and the nurse's name.

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

Which part of the client's record is commonly used to document specific client variables, such as vital signs?

flow sheets

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest?

charting by exception

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation?

charting by exception

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 nurse is working as part of a team that has been asked to address the issue of confidentiality and documentation of client health information electronically. Which activity(ies) will the team suggest to help ensure confidentiality? Select all that apply.

having each person responsible for documenting in the electronic health record not share his or her password placing computer screens in locations that face away from any public areas such as hallways ensuring that individuals log off a computer terminal when documentation is completed

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data.

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.

A nurse charting the health care record for a client knows that which form of charting involves writing information about the client and client care in chronological order?

narrative charting

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

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself 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 the client is supposed to be on, the nurse 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.

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which technique would be most appropriate for the nurse to use when communicating with the health care provider?

SBAR

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

The nurse is documenting care for a client with diabetes. Which nursing documentation will The Joint Commission review? Select all that apply.

nursing care provided physical assessment nursing diagnoses client teaching

A nurse is making a home visit to a client for the first time. The nurse is documenting assessment information on a laptop computer as each aspect of the assessment is completed. The nurse is using:

point-of-care documentation.

A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. The nurse demonstrates understanding of this method by identifying what as the first step?

problem selected

Alice Jones, a registered nurse, is documenting pain assessment after the administration of pain medication in the client's medical record. How should the nurse document this assessment?

Client rates pain at 2 on a scale of 0-10. A. Jones, RN

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

urine output 100 ml

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