Prep U: Documentation Ch. 19
According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?
documentation
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.
The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given?
2130
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.
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 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 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 client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. The other answers are therefore inappropriate responses.
An informatics nurse specialist is gathering data from electronic health records at the facility about clients who have had central venous catheters inserted for more than the recommended time as specified by the facility's protocol. The nurse specialist is collecting this data most likely for which purpose?
Identify clients risk for infection
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.
current orders any abnormal occurrences with the client during the shift identifying demographics, including diagnosis
Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?
"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."
