TAYLOR chapter 16 review questions. Documenting, Reporting, Conferring, and Using Informatics

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

.D. "A coronary artery bypass graft will benefit your heart."

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

A. "I will arrange access for you to review the record after you put your request in writing."

Which documentation tool will the nurse use to record the client's vital signs every 4 hours? A. A flow sheet B. 24-hour fluid balance record C. Acuity charting forms D. Medication record

A. FLOW SHEET

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate? A. "CBE is a relatively new format of documentation in electronic health records." B. "The benefit of CBE is less time needed on computer charting." C. "The benefit of CBE is it demonstrates whether high quality care is given." D. "CBE is the best way to protect against lawsuits."

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

What ensures continuity of care?

COMMUNICATION communication ensures continuity of care and provides essential data for revision or continuation of care.

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. conferring. B. a consultation. C. reporting. D. a referral.

D. REFERRAL

A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results? A. Flow sheets B. Medical records C. Progress notes D. Graphic sheets

D. graphic sheet

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.

A concise document that provides most of the client's nursing and medical information is a(n):

KARDEX The Kardex is a way to ensure continuity of care from one shift to another and from one day to the next.

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? A. "Only authorized persons are allowed to access client records." B. "Let me get that for you." C. "The provider will need to give permission for you to review." D. "I am sorry I can't access that information."

ONLY AUTHORIZED PERSON ARE ALLOWED TO ACCESS CLIENT'S RECORD

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and:

REIMBURSEMENT Audits of client records serve a dual purpose: quality assurance and reimbursement.

During hospitalization, the client has developed shortness of breath, with edema. What action should the nurse take?

REVISE PLAN OF CARE A plan of care should be generated at admission and revised to reflect changes in the client's condition.

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

B. urine output 100 ml

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

USE MINIMUM DISCLOSURE POLICY TO RELEASE INFORMATION. nurse should use minimum disclosure policy to release information, as per HIPAA regulations.

Which method of charting did the nurse use to document "fluid overload. on assessment client's lower limb oedmatous ++. Affected leg elevated and lasix 40 mg IM given. No signs of DVT noted. LIMBS now edema +"? A. focus charting B. narrative charting C. pie charting D. exception charting

FOCUS CHARTING focus charting gives priority attention to client's current or changed behavior. PIE charting occur when nurse records client's progress under the headings of problem, intervention , and evaluation. NARRATIVE CHARTING contents resembles log or journal entry. CHARTING BY EXCEPTION is charting only abnormal assessment findings that deviate from a standard norm.

A nursing student asks a nurse why nurses cannot document in a separate record (instead of the client record) in order to document and find the information needed. What is the best response by the nurse? A."Legal policy requires nursing practice to be permanently integrated into the client record." B. "The facility requires us to document client care this way because of the software used." C. "It would be easier to do it that way. You could develop a tool to use." D. "The electronic health record we use does not allow us to use different formats."

A. "Legal policy requires nursing practice to be permanently integrated into the client record."

Besides being an instrument of continuous client care, the client's health care record also serves as a(an): A. incident report. B. assessment tool. C. legal document. D. Kardex.

C. legal document

How can the nurse researcher obtain information from a client record.? A. audit discharge records B. examine institutional procedures C. study client records D. interview nursing staff

C. study client records

A nurse is caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record? A. to transmit health records between insurance companies B. to release the entire health record for research C. to inform family and others concerned about the client's care D. to investigate quality of care in the agency

D. to investigate quality of care in the agency

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which information would the nurse expect to include when preparing the verbal handoff report? A. Client's family members B. Client's intake for previous meal C. Current client assessment D. Client's admission number

A. CURRENT CLIENT ASSESSMENT

Which statement by the nurse is the best example of an internal communication strategy the nurse should use to discuss the use of new equipment, client care problems, and change in policies? A. "We will discuss the new policies at the change-of- shift report." B. "We will be having a team conference to discuss concerns that clients' relatives have raised." C. "You will demonstrate the use of the cardiac monitor on the nursing rounds." D. "You will see the procedure for using the new equipment in the client assignments."

B. "We will be having a team conference to discuss concerns that clients' relatives have raised."

A nurse ask why completing acuity report is important? What is the best response by the nurse? A. "It provides the pharmacy with the newest health care provider prescription." B. "It determines if a client needs to be transferred to a different unit." C. "It's the beginning step in determining the plan of care for the client." D. "It helps determine our staffing requirements."

IT HELPS DETERMINE OUR STAFFING REQUIREMENTS Acuity report includes determining number of staff needed to care for clients on the unit.

Which characteristic of a nurse's charting will assist most n the avoidance of errors? A. Subjectivity B. Brevity C. Timeliness D. Detail

TIMELINESS documentation in timely manner ca help avoid errors.

Which information the nurse is expected to fin on the nursing KARDEX?

level of activity, current medical order, and preparedness for a investigation are current information about client's care are expected to see on nursing KARDEX

A nurse is using SOAP format for documentation to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurses focus when completing this documentation? A. patient problem list B. notes describing the patient's condition C. overall trend in patient's status D. planned intervention and patient's outcome

A. patient problem list

When maintaining health care records for a client, the nurse knows that a health care records also serves as a legal document of evidence. what should the nurse do to ensure legal defensible charting?

ensure that clients name appear on all pages nurse should ensure that client's name appear on all pages to ensure legally defensible charting. Nurse should record all facts but not any subjective interpretations, to ensure that document is legal evidence

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting? A. Ensure that the client's name appears on all pages. B. Leave spaces between entries and signature. C. Record all facts and subjective interpretations. D. Use abbreviations wherever possible.

A. Ensure that the client's name appears on all pages.

Which of the following information about the patient would a nurse include as part of minimum data set when using electronic medical records? select all that apply A. sex/gender B. physical assessment C. insurance D. admission date E. health history

A. sex/gender C. insurance D. admission date minimum data set is organized into three categories: 1. nursing care elements (diagnoses and intervention 2. patient demographic element (sex, date of birth, ethnicity 3. service elements (admission and discharge dates and unexpected payer of service.

The nurse completed minimum data set for a newly admitted client to a skilled nursing facility. Which action by the nurse is most appropriate? A. Document the findings on an occurrence report. B. Repeat the minimum data set in 2 weeks. C. Assess the triggers from the data. D. Provide a comprehensive written report to the client ombudsperson.

ASSESS THE TRIGGERS FROM THE DATA once data set is complete, it will identify elements or triggers for issues that the resident has or is at risk for developing

A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDA) in bedside care. This study is tangible application of what? A. telemedicne B. nursing informatics C. electronic medical records D. computerized documentation

B. nursing informatics nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.

A nurse in long term care facility is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent? A. flow sheet B. SOAP note C. Narrative note D. PIE note

C. NARRATIVE NOTE A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, client activity pattern, and comfort measures provided, along with the client's response.

A nurse helps a client who has cystic fibrosis prepare a stand alone personal health record. Which statement by the nurse best explains this type of information? A. "Your entire health care team may access and securely share your vital medical information electronically." B. "Your health care provider is obligated to read your personal health record and share it with your insurance provider." C. "You can fill in information from your own records and store it on your computer or the Internet." D. "You can link your record to a specific health care organization's electronic health record system."

C. YOU CAN FILL INFORMATION FROM YOUR OWN RECORDS AND STORE IT IN YOUR COMPUTER OR THE INTERNET.

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? A. Variance charting B. Problem, Intervention, Evaluation (PIE) charting C. Charting by exception (CBE) D. FOCUS charting

C. charting by exception

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? A. Problem-oriented recording has numerous locations for information where each member of the multidisciplinary team makes entry about their own specific activities in relation to the client's care. B. Problem-oriented recording is difficult to demonstrate a unified approach for resolving the clients' problem among caregivers. C. Problem-oriented recording gives the clients the right to withhold the release of their information to anyone. D. Problem-oriented recording emphasizes goal- directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

D. Problem-oriented recording emphasizes goal- directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

When recording data regarding client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan of care of the client. Which of the following styles of documentation is the nursing implementing? A. PIE charting B. Narrative charting C. Focus carting D. SOAP charting

D. SOAP charting Narrative- is a time consuming to write and read, caregiver must sort through lengthy notation for specific information that correlates client's problem with care and progress FOCUS- follows DAR model PIE- method of recording client's progress under the heading of problem, intervention, and evaluation

Which flow sheet provides the health care provider with information on an ongoing record of fluid loss? A. Health assessment flow sheet B. Vital signs graphic sheet C. Critical care flow sheet D. Intake and output graphic sheet

D. intake and output graphic sheet

A hospital is switching to computerized charting. the nurse recognizes that one advantage to an electronic client chart is what? A. No other charting method is necessary B. it is less costly to maintain C. access is open to anyone D. retrieval of information is more efficient

D. retrieval of information is more efficient

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

Problem-oriented method The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care. Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on.

Health care facility plan to evaluate and revise the plan of care for a client based on the client's health care records. Physician, dietitian, and nurse involved in 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's detail? A. Narrative charting B. FOCUS charting C. SOAP charting D. PIE charting

SOAP CHARTING SOAP charting, everyone involved in care makes entries in the same location in the chart NARRATIVE charting is time consuming to write and read, as it is involved sorting through the lengthy notations FOCUS charting follows DAR(data, action,response) model PIE charting is a method of recording the client's progress under the heading of problem, intervention, and evaluation.

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 Telemedicine and mobile health technology facilitate client engagement, while helping providers deliver more cost-effective care. Telemedicine embraces applications and services that include two-way video communications, e-mail, and wireless phones.

A nurse is documenting care in a source oriented record. what action by the nurse is most appropriate?

WRITE A NARRATIVE NOTE IN THE DESIGNATED NURSING SECTION source oriented record have separate sections for each discipline to document their own information.

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

C. the nurse provides information over the phone to the client's family ember who lives in a neighboring state

Meaningful use of technology in client's care and management is goal for everyone involved. The transition for paper to electronic charting generates mixed responses from nurses. Which agency is responsible for monitoring compliance to health information technology for economic and clinical health (HITECH) A. Department of Social Services B. The Joint Commission C. Center for Medicare and Medicaid services D. World Health Organization

CENTER FOR MEDICARE and MEDICAID SERVICES HITECH established to create incentives for professionals and agencies to receive financial payment for the meaningful use of technology to improve client care

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 Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in CBE narrative- style notes. The question is asking about a pregnant woman with hypertension. This is not an expected situation for a typical pregnant woman, so CBE is a way to document this situation so that it will be immediately seen in the documentation. The PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). This would not be the best method of documentation if the nurse wanted the documentation to stand out regarding the client's condition. Narrative notes address routine care, normal findings (findings that do not call for changes in the plan of care), and client problems identified in the plan of care. SOAP notes (Subjective data, Objective data, Assessment, Plan) is used to organize entries in the progress notes, focusing primarily on the client and any identified problems.

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 team would most likely suggest the use of charting by exception, which is an abbreviated form of documentation. Narrative notes are time-consuming to write and require much reading to learn about a specific problem. The problem, intervention, and evaluation note system simplifies documentation by incorporating the plan of care into the progress notes. The FOCUS system of documentation organizes entries by data, action, and response. This system is broader in its view because a FOCUS can be a problem area, but does not need to be.

Which statement regarding FOCUS charting is most accurate? A. The charting focuses on the injury or illness only. B. Each note should include each section of the Data, Action, Response (DAR) format of charting. C. Problem, Intervention, Evaluation (PIE) charting is used with focused charting. D. The charting focuses on client strengths, problems, or needs.

CHARTING FOCUSES ON CLIENT'S STRENGTHS, PROBLEMS, OR NEEDS

Nurse is maintaining a problem oriented medical record fora client. which component of the record describes the client's responses to what has been done and revisions to the initial plan?

PROGRESS NOTE In problem oriented medical record, progress note describe client's response to what has been done and revision initial plan