#05 - Chapter 20: Documenting and Reporting
A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is MOST appropriate? A) It will allow for us to see the client and possibly increase client participation in care B) It will let me see everything that has been done and things that need to be done C) It makes our client feel like we care, especially if we start the day off with a clean room D) It will give a better sense of what my workload will be today
A) It will allow for us to see the client and possibly increase client participation in care Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.
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? A) SBAR B) SOAP C) PIE D) MAR
A) SBAR 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.
Which documentation by the nurse BEST supports the PIE charting system? A) vomiting 250 mL undigested food, antiemetic given, no further vomiting B) states nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given C) vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg D) blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea
A) vomiting 250 mL undigested food, antiemetic given, no further vomiting PIE charting includes the problem, intervention, and evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (problem), antiemetic given (intervention), no further vomiting (evaluation).
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? A) The hospital owns your records and does not have to allow you access while you are a client here B) I will have to review the policy that determines what procedure is in place for client access C) Let me open up the computer access so that you can see what information is of interest to you D) You may not understand all of the information and it will confuse you so I will help you decipher it all
B) I will have to review the policy that determines what procedure is in place for client access Clients have the right to see their own medical records and request changes to documentation that may be in error. Most facilities have a policy in place for the client to obtain medical records and the nurse should ensure that the policy is followed by being familiar with that policy prior to giving the client free access to the record. The nurse should not demean the client by assuming that the information may be confusing. The nurse should not allow the client access to the computer while using the nurse's password or login information. While the hospital maintains responsibility for the record, the client has the right to see it.
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? A) FOCUS charting B) SOAP charting C) PIE charting D) narrative charting
B) SOAP charting 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.
A nurse administrator is participating in an audit that has the goal of creating a quality improvement plan. Which organization will the nurse be reporting to? A) Occupational Health and Safety Administration B) American Nurses Association C) The Joint Commission D) National League of Nursing
C) The Joint Commission The Joint Commission audits client records regularly under specific guidelines that are announced annually and shared with each institution. The Joint Commission also encourages institutions to set up ongoing quality assurance programs. The National League for Nursing and the American Nurses Association are professional nursing organizations that provide services to nurses; they do not audit client records. The Occupational Health and Safety Administration is not involved directly in the quality of client care.
Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in charting? A) "If I make an error, I can draw a red circle around it." B) "If I make an error, I have to rewrite the entire entry." C) "If I make an error, I use white out on it." D) "If I make an error, I draw a single line through it and put my initials by it
D) "If I make an error, I draw a single line through it and put my initials by it." When an error occurs, the nurse should draw a single line through the error and place his or her initials above it. If the nurse is using an EMR (electronic medical record), and the documentation cannot be changed - this will require an addendum.
The nurse is transfusing multiple units of packed red blood cells. After the second unit of 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? A) I am calling because the client receiving blood has developed dyspnea and had crackles B) This client has a medical history of heart failure C) It seems like this client has fluid volume overload D) I think the client would benefit from intravenous furosemide
D) I think the client would benefit from intravenous furosemide Situation, background, assessment, and recommendations (SBAR) provides a consistent method for hand-off communication that is clear, structured, and easy to use. The S (situation) and B (background) provide objective data, whereas the A (assessment) and R (recommendations) allow for presentation of subjective information. Calling to report dyspnea and crackles occurs as the nurse describes the situation. Providing the medical history occurs as the nurse offers important background information. Stating that the client has fluid volume overload is the assessment of the nurse. Stating that the nurse thinks the client would benefit from intravenous furosemide is the nurse's recommendation.
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? A) The UAP will tell me what the vital signs are, and I will record them in the record so the health care provider can review them B) Vital signs do not need to be recorded unless they are abnormal C) The UAP logs in under my name and documents the vital signs D) The UAP is able to log in and enter the information so all members of the health care team see it
D) The UAP is able to log in and enter the information so all members of the health care team see it Each person who makes entries in the client's electronic health record (EHR) is responsible for the information he or she records and can be summoned as a witness to testify concerning what has been documented. Although the licensed registered nurse has accountability, the UAP can document data that has been collected in the EHR. It is not appropriate to document for someone else, and all users should always log out of the computer prior to allowing another person to document.
A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? A) 1 Unit of glucose B) 1 bottle of glucose C) One U of glucose D) 1 U of glucose
A) 1 Unit of glucose The nurse should write "1 Unit of glucose." The nurse cannot write "1 bottle" or "one U of glucose" because these are not the accepted standards. "1U" is an abbreviation that appears in the JCAHO "Do Not Use" list (see http://www.jcaho.com). It should be written as "1 Unit" instead of "1U" because "U" is sometimes misinterpreted as "zero" or "number 4" or "cc."
Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A) A client has asked a nurse if he can read the documentation that his health care provider wrote in his chart B) A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test C) A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer D) A client who resides in Indiana has required hospitalization during a vacation in Hawaii
A) A client has asked a nurse if he can read the documentation that his health care provider wrote in his chart 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.
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? A) "Any information that can identify a person is considered a breach of client privacy." B) "You may continue to post about a client, as long as you do not use the client's name." C) "All aspects of clinical practice are confidential and should not be discussed." D) "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."
A) Any information that can identify a person is considered a breach of client privacy." Any information that can identify a person is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the facility and unit is disclosed in the post. Discussion of clinical practice can be helpful for learning purposes or seeking advice on care. No care should be discussed, even privately, with friends and family without first obtaining the client's permission.
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? A) I will arrange access for you to review the record after you put your request in writing B) No, the health care provider will not give you access to review the records C) Are you questioning the care of your child D) Only the client has the right to review the health care records
A) I will arrange access for you to review the record after you put your request in writing 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.
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? A) I will arrange access for you to review the record after you put your request in writing B) No, the health care provider will not give you access to review the records C) Are you questioning the care of your child? D) Only the client has the right to review the health care records
A) I will arrange access for you to review the record after you put your request in writing 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.
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 A) S: The nurse handling the transfer describes the client situation to the new nurse B) S: The nurse discusses the client's symptoms with the new nurse in charge C) B: The nurse gives the background of the client by explaining the client history D) A: The nurse presents an assessment of the client to the new nurse E) R: The nurse explains the rules of the new facility to the client F) R: The nurse gives recommendations for the future care to the new nurse in charge
A) S: The nurse handling the transfer describes the client situation to the new nurse C) B: The nurse gives the background of the client by explaining the client history D) A: The nurse presents an assessment of the client to the new nurse F) R: The nurse gives recommendations for the future care to the new nurse in charge Examples of using the SBAR technique are numerous. The nurse handling the transfer describes the client situation to the new nurse. The nurse gives the background of the client by explaining the client history. The nurse presents an assessment of the client to the new nurse. The nurse gives recommendations for future care to the new nurse in charge. The nurse does not explain the rules of the new facility to the client as part of the SBAR technique. The nurse would discuss the client's symptoms with the new nurse in charge as part of the "B" background, not the "S" situation.
A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? A) a client who is homebound and needs skilled nursing care B) a client whose rehabilitation potential is not good C) a client whose status is stabilized D) a client who is not making progress in expected outcomes of care
A) a client who is homebound and needs skilled nursing care Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.
A client is scheduled for a CABG procedure. What information should the nurse provide to the client? A) A coronary artery bypass graft will benefit your heart B) The CABG procedure will help identify nutritional needs C) A complete ablation of the biliary growth will decrease liver inflammation D) The CABG procedure will help increase intestinal motility and prevent constipation
A) a coronary artery bypass graft will benefit your heart Coronary artery bypass graft is abbreviated CABG. It does not identify nutritional needs, decrease liver inflammation, or increase intestinal motility.
The parent of a 33 year old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is MOST appropriate? A) Ask the client if information can be given to the parent B) Provide the information to the parent C) Explain the reasons for the hospitalization, but give no further information D) Take the parent to the client's room and have the client give the requested information
A) ask the client if information can be given to the parent No information should be provided by the nurse without permission from the client. Taking the parents to the client's room to get information from the client may violate the client's privacy.
The nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse BEST demonstrates understanding of client privacy? A) calling the client information desk to find out the room number of the family member B) finding the emergency medical technicians who transported the family members and inquiring about the injuries C) asking the emergency department nurse for information of the family member D) accessing the electronic health record of the family member to find out extent of injury
A) calling the client information desk to find out the room number of the family member Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.
A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? A) client's record and occurrence report B) occurrence report and critical pathway C) critical pathway and care plan D) care plan and client's record
A) client's record and occurrence report An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.
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? A) identifying risks and ensuring future safety for clients B) gauging the nurse's professional performance over time C) protecting the nurse and the hospital from litigation D) following up the incident with other members of the care team
A) identifying risks and ensuring future safety for clients 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.
Which statement is not true regarding a medication administration record (MAR)? A) If the client declines the dose, the nurse does not have to document this on the MAR B) The MAR distinguishes between routine and "as needed" medications C) The MAR identifies routine times for medication administration D) After using an electronic MAR, the nurse should log off
A) if the client declines the dose, the nurse does not have the document this on the MAR If a client declines a dose, the nurse should circle that dose and write a note as to why the nurse did not administer it. MARs can distinguish between routine and "as needed" medications identify routine times for medication administration. After using an electronic MAR, the nurse should log off to prevent others from inadvertently adding information about other clients to the initial client's record.
Which statement is not true regarding a medication administration record (MAR)? A) if the client declines the dose, the nurse does not have to document this on the MAR B) The MAR distinguishes between routine and "as needed" medications C) The MAR identifies routine times for medication administration D) After using an electronic MAR, the nurse should log off
A) if the client declines the dose, the nurse does not have to document this on the MAR If a client declines a dose, the nurse should circle that dose and write a note as to why the nurse did not administer it. MARs can distinguish between routine and "as needed" medications identify routine times for medication administration. After using an electronic MAR, the nurse should log off to prevent others from inadvertently adding information about other clients to the initial client's record.
The nurse caring for an older adult client suspects that the client is being neglected at home due to several observations obtained in the ongoing assessment. What is the appropriate nursing actions in this situation? A) immediately report the suspected abuse of the client B) avoid reporting the abuse as it would be a privacy and confidentiality violation C) inform the client's family that the client is being neglected at home D) discuss the abuse with coworkers to determine what should be done
A) immediately report the suspected abuse of the client The nurse is a mandatory reporter and state laws take precedence over Health Insurance Portability and Accountability Act (HIPAA)/ Personal Information Protection and Electronic Document Act (PIPEDA) regulations. The priority action by the nurse is to report the suspected abuse to the adult protective service department so that it can be investigated. It is not appropriate to involve the family members at this point because it may mask any abuse that is occurring. The fewer people involved in this situation is better. The nurse should not discuss this with coworkers unless they are directly involved with the client's care.
A nurse is requesting the receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is MOST appropriate? A) It will allow for us to see the client and possibly increase client participation in care B) It will let me see everything that has been done and things that need to be done C) It makes our client feel like we care, especially if we start the day off with a clean room D) It will give me a better sense of what my workload will be today
A) it will allow for us to see the client and possibly increase client participation in care Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: A) limiting abbreviations to those approved for use by the institution B) using only abbreviations whose meaning is self-evident to an educated health professional C) ensuring that abbreviations are understandable to clients who may seek access to their health records D) using only those abbreviations that are defined in full at another location in the client's chart
A) limiting abbreviations to those approved for the use by the institution 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.
Which are appropriate actions for protecting clients' identities? Select all that apply A) place light boxes for examining X-rays with the client's name in private areas B) ensure that clients' names on charts are visible to the public C) document all personnel who have accessed a client's record D) have conversations about clients in private places where they cannot be overheard E) orient computer screens toward the public view
A) place light boxes for examining X-rays with the client's name in private areas C) document all personnel who have accessed a client's record D) have conversations about clients in private places where they cannot be overheard Documenting all personnel who have accessed a client's record, placing light boxes for examining X-rays with the client's name in private areas, and having conversations about clients take place in private where they cannot be overheard are useful strategies to limit casual access to the identity of clients and health informatics. Orienting computer screens toward the public view and visibly displaying clients' names on charts are incorrect, as these are breaches of client confidentiality.
A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse BEST reflects the effectiveness of the pain medication? A) Rates pain 8/10, states nauseated for last 30 minutes B) States pain is not relieved, talking with family on phone C) Vital signs within normal limits, sleeping D) Rates pain higher on pain scale, notified health care provider
A) rates pain 8/10, states nauseated for last 30 minutes Using the pain scale gives a more objective and measurable evaluation of pain. Stating "Vital signs within normal limits, sleeping" does not evaluate effectiveness of the pain medication. The statement of pain not being relieved or pain higher on pain scale does not provide a definitive measurement of effectiveness in the documentation.
What actions should the nurse take before making an entry in a client's record? Select all that apply A) reviewing the agency's list of approved abbreviations B) choosing the charting format that the nurse prefers C) locating clients' files within an electronic health record system D) identifying the form appropriate to be used for documenting E) checking the clients' names are not identified within the chart forms
A) reviewing the agency's list of approved abbreviations C) locating clients' files within an electronic health record system D) identifying the form appropriate to be used for documenting The nurse should review the agency's list of approved abbreviations, as each agency may use a different set of approved abbreviations and has approved its use for legally defensible reasons. The nurse should locate clients' files within an electronic health record system rather than creating a new record, to avoid duplication and missing important information in the client's record that was added previously. The nurse should identify the form appropriate to use for documenting, because some aspects of clients' care are recorded on specific forms. The nurse should use the charting format required by the facility, not choose one that the nurse prefers. The client's name should be identified on chart forms, so that if the forms become separated from the chart, the nurse will still be able to identify which client chart they belong to.
The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? A) subjective data should be included when documenting B) objective data are what the client states about the problem C) the plan includes interventions, evaluation, and response D) abnormal laboratory values are common items that are documented
A) subjective data should be included when documenting Subjective data should be included when using the SOAP format for documentation. Objective data are what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care provider's judgment of the situation, and abnormal lab values would be included in objective data.
The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? A) subjective data should be included when documenting B) objective data are what the client states about the problem C) the plan includes interventions, evaluations, and response D) abnormal laboratory values are common items that are documented
A) subjective data should be included when documenting Subjective data should be included when using the SOAP format for documentation. Objective data are what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care provider's judgment of the situation, and abnormal lab values would be included in objective data.
Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? A) submitting a written notice to all clients identifying the uses and disclosures of their health information B) disclosing client health information for research purposes after obtaining permission from the client's health care provider C) releasing the client's entire health record when only portions of the information are needed D) obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information
A) submitting a written notice to all clients identifying the uses and disclosures of their health information Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the health care provider's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations.
A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? A) the lower extremities B) lung sounds C) heart rate and rhythm D) the abdominal area
A) the lower extremities Peripheral vascular disease mostly affects the lower extremities. While the lung sounds, heart rate and rhythm, and abdominal assessment will be important, the focused assessment should be on the lower extremities.
The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? A) write the order in the client's record B) inform the health care provider that a written order is needed C) call the pharmacy to have the order entered in the electronic record D) add the new order to the medication administration record
B) inform the health care provider that a written order is needed Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.
Which note includes all elements of a SOAP note? A) Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess B) 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 C) Client reports nausea and vomiting x 3 days. Vital signs stable. Most likely due to gastroenteritis D) Client reports nausea, vomiting, and diarrhea x 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min
B) Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good tugor. 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 A SOAP note consists of subjective information, objective information, an assessment, and a plan. The correct response includes each of these while the remaining three responses are each lacking a different one of the components.
Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? A) 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 B) 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 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
B) 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 SBAR refers to: S (situation): what is the situation you are calling about?; B (background): pertinent background information related to the situation; A (assessment): what is your assessment of the situation?; R (recommendation): explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.
Which example may illustrate a breach of confidentiality and security of client information? A) The nurse provides information over the phone to the client's family member who lives in a neighboring state B) The nurse provides information to the professional caregiver involved in the care of the client C) The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria D) The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell
B) The nurse provides information over the phone to the client's family member who lives in a neighboring state 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.
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) A never event B) A variance C) An audit D) A sentinel event
B) a variance 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.
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) a never event B) a variance C) an audit D) a sentinel event
B) a variance 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.
The nurse documents a progress note in the wrong client's electronic health record (EHR). Which action would the nurse take once realizing the error? A) Immediately delete the incorrect documentation B) create a notation with a correction C) contact information technology (IT) staff to make the correction D) contact the health care provider
B) create a notation with a correction If the nurse is using an electronic health record (EHR) and the documentation cannot be changed, an notation will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies. The health care provider does not need to be contacted to make a correction, but does need to be informed if this caused any direct harm or effects to the client.
The nurse documents a progress note in the wrong client's electronic health record (EHR). Which action would the nurse take once realizing the error? A) immediately delete the incorrect documentation B) create a notation with the correction C) contact information technology (IT) staff to make the correction D) contact the health care provider
B) create a notation with the correction If the nurse is using an electronic health record (EHR) and the documentation cannot be changed, an notation will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies. The health care provider does not need to be contacted to make a correction, but does need to be informed if this caused any direct harm or effects to the client.
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: A) factural statement B) interpretation of data C) important information D) relevant data
B) interpretation of data 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.
Which actions should the nurse perform to limit casual access to the identify of clients? Select all that apply A) posting information and linking a client with diagnosis, treatment, and procedure on whiteboards B) obscuring identifiable names of clients and private information about clients on clipboards C) placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public D) keeping records of people who have access to clients' records E) making the names of clients on charts visible to the public
B) obscuring identifiable names of clients and private information about clients on clipboards C) placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public D) keeping record of people who have access to clients' records 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; and keeping record of people who have access to clients' records are required under the Health Insurance Portability and Accountability Act (HIPAA), which is legislation that attempts to limit casual access to the identity of clients. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards and making the names of clients on charts visible to the public are violations of HIPAA, as these activities allow casual access to the identity of clients.
Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. A) posting information linking a client with diagnosis, treatment, and procedure on whiteboards B) obscuring identifiable names of clients and private information about clients on clipboards C) placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public D) keeping record of people who have access to clients' records E) making the names of clients on charts visible to the public
B) obscuring identifiable names of clients and private information about clients on clipboards C) placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public D) keeping record of people who have access to clients' records 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; and keeping record of people who have access to clients' records are required under the Health Insurance Portability and Accountability Act (HIPAA), which is legislation that attempts to limit casual access to the identity of clients. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards and making the names of clients on charts visible to the public are violations of HIPAA, as these activities allow casual access to the identity of clients.
The following statement is documented in the client's health record: "Client c/o severe H/A upon arising this morning." Which interpretation of this statement is MOST accurate? A) The client has symptoms in the morning associated with a heart attack B) the client reports waking up this morning with the severe headache C) the client is coughing and experiencing severe heartburn in the morning D) the client has a history of severe complaints in the morning
B) the client reports waking up this morning with the severe headache 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.
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? A) the nurse consults with someone in order to exchange ideas or seek information, advice, or instructions B) the nurse meets with nurses or other health care professionals to discuss some aspect of client care C) the nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care D) the nurse sends or directs someone to take action in a specific nursing care problem
B) the nurse meets with nurses or other health care professionals to discuss some aspect of client care A nursing care conference is a meeting of nurses to discuss some aspect of a client's care.
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? A) Chart at least every 6 hours B) use point-of-care documentation whenever possible C) summarize client care thoroughly at the end of the shift and complete documentation for the shift D) delegate charting appropriately to unlicensed assistive personnel
B) use point-of-care documentation whenever possible 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.
The nurse is calling a health care provider to give an update on a client's condition. The nurse receives a telephone order and, when requests that the order be read back to the provider for confirmation, the provider states, "I don't have time for this." What is the MOST appropriate action by the nurse? A) Proceed with the order since the nurse heard it the first time B) Don't follow through with the order, and delete it from the record C) Inform the provider, to ensure safety for the client, it must be read back D) Ask the secretary to call the provider back and take the order
C) Inform the provider, to ensure safety for the client, it must be read back It is important for confirmation that a verbal or telephone order be read back. If another RN is available, two RNs should be listening on the phone when the order is given. An order should never be deleted from the record, because anything written is a permanent part of the record. The secretary should not be taking verbal or telephone orders, because it is outside of the scope of practice for that position.
A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift? A) No medical issues overnight that require immediate attention B) The unlicensed assistive personnel turned the client every 2 hours last night, but the client should continue to be repositioned during the day C) The client had a good deal of anxiety last night and requested to be turned and repositioned frequently D) The client was very restless last night so you may need to call the health care provider today to get a prescription for the client's anxiety
C) The client had a good deal of anxiety last night and requested to be turned and repositioned frequently In inpatient settings, the handoff that occurs when a new shift starts is often referred to as the change-of-shift report. This ensures continuity of client care from one shift to the next, allowing the oncoming nurse to receive information regarding the client's status or plan of care. The handoff should include objective information regarding the status of the client such as mental status, pain issues, and care performed. Subjective information is also in the handoff. This includes statements regarding anxiety. Brief, undescriptive statements are not comprehensive enough and positioning of the client, while important, is not thorough enough. Statement regarding restlessness may be important and the provider may need to be contacted, but this is not the most effective way to communicate information needed in the hand-off.
A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? A) a client whose status is stabilized B) a client who is not making progress in expected outcomes of core C) a client who is homebound and needs skilled nursing care D) a client whose rehabilitation potential is not good
C) a client who is homebound and needs skilled nursing care Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes 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) a consultation B) conferring C) a referral D) reporting
C) a referral 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.
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 A) what the client watched on television during the shift B) what time the nurse will return for the next shift C) any abnormal occurrences with the client during the shift D) identifying demographics, including diagnosis E) current orders
C) any abnormal occurrences with the client during the shift D) identifying demographics, including diagnosis E) current orders 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.
A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? A) occurrence report and critical pathway B) critical pathway and care plan C) client's record and occurrence report D) care plan and client's record
C) client's record and occurrence report An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.
The nurse mistakenly documented one client's assessment data on another client's health care record. What action should the nurse take? A) use a dark-colored felt-tip pen to black out the error B) replace the record sheet and write the correct entry on the new sheet C) draw a single line through the error, initial it, and write the correct entry D) use correction fluid to cover the error and write the correct entry over it
C) draw a single line through the error, initial it, and write the correct entry Draw a single line through an incorrect entry, write the words "mistaken entry" or "error in charting" above or beside the entry, and initial it. Then rewrite the entry correctly. The other options are not appropriate ways to correct an erroneous entry.
Which practice should the nurse adopt when communicating and documenting electronically? A) seek client permission before posting information on social media B) avoid using client names if emailing information on an unencrypted network C) include precise measurements in documentation rather than approximations D) avoiding using names of health care providers
C) include precise measurements in documentation rather than approximations Precise measurements and times must be used whenever possible. Client information should never be sent over an unencrypted email network, and social media posts should never include any references to clients, regardless of permission. It is appropriate to use health care providers' names in documentation.
Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? A) recording nursing interventions B) identifying nursing diagnoses or clients' needs C) Omitting clients' responses to nursing interventions D) documenting clients' health histories and discharge planning
C) omitting clients' responses to nursing interventions Omitting clients' responses to nursing interventions is correct because it does not fit the criteria for legally defensible charting. Recording nursing interventions, identifying nursing diagnoses or client needs, and documenting clients' health histories and discharge planning are all criteria for legally defensible charting and would demonstrate evidence of quality care.
The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? A) Let me get that for you B) the provider will need to give permission for you to review C) only authorized persons are allowed to access client records D) I am sorry I can't access that information
C) 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.
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 advantages of using problem-oriented records? A) problem-oriented recording gives clients the right to withhold the releases of their information to anyone B) problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers C) 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 has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care
C) problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers is an advantage of problem-oriented recording and is therefore correct. Giving clients the right to withhold the release of their information to anyone is a beneficial disclosure and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving clients' problems among caregivers and having numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care are examples of source-oriented recording.
A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan? A) data base B) problem list C) progress notes D) plan of care
C) progress notes In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.
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? A) dialogue B) documentation C) reporting D) verification
C) reporting Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. Some facilities may use encrypted (protected) software programs such as SharePoint or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.
Which is not a purpose of the client care record? A) to serve as a legal document B) to facilitate reimbursement C) to serve as a contract with the client D) to assist with care planning
C) to serve as a contract with the client Client care records are legal documents, communication tools, and assessment tools. They are used for care planning, quality assurance, reimbursement, research, and education. They in no manner reflect a contract between health care staff and the client. The only exception to this is at the point of admission when the client (or responsible party) signs an acknowledgement of expenses about to be incurred as health care insurance information is obtained.
A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with the client translator? A) talking directly to the translator facilitates the transfer of information B) talking loudly helps the translator and the client understand the information better C) translators may need additional explanation of medical terms D) It is always okay to not use a translator if a family member can do it
C) translators may need additional explanation of medical terms When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times.
Which note includes ALL elements of a SOAP note? A) Client reports nausea, vomiting, and diarrhea x 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. B) Client reports nausea and vomiting x 3 days. Vital signs stable. Most likely due to gastroenteritis C) Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess D) 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
D) 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 A SOAP note consists of subjective information, objective information, an assessment, and a plan. The correct response includes each of these while the remaining three responses are each lacking a different one of the components.
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? A) Client is requesting, pain medications, is grimacing, and is diaphoretic B) Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants C) Client states expecting some pain, but it is more severe than anticipated D) Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."
D) Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." In the SOAP format, "S" refers to subjective data, which are usually recorded as the client's statement or anything verbalized by the client. The statement about pain secondary to postoperative status and increased activity reflect the "A," or assessment, portion of the SOAP format. The statements about the abdomen being soft, bowel sounds, and so on reflect the "O," or objective data, portion of the SOAP format. The statement about physical manifestations of pain is not subjective data.
A nurse is documenting client care using SOAP format. Place the statements listed below in the order that the nurse would record them. (Arrange in order) A) Fever, possible urinary tract infection B) Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. C) Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. D) I don't feel well. I've been urinating often, and it burns when I urinate.
D) I don't feel well. I've been urinating often, and it burns when I urinate B) Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees *F. Indwelling urinary catheter removed 2 days ago A) Fever, possible urinary tract infection C) Notify Dr. Phillips of fever and client complaints When using the SOAP format, the nurse would first document the subjective data (S: the client's complaint), objective data (O: abdomen, urine characteristics, temperature and contributing factors), assessment (A: caregiver's judgment about the situation—fever and possible urinary tract infection), and plan (P: what the caregiver is going to do—notify the health care provider, encourage fluids, and continue to monitor).
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? A) I am concerned that the client might be exhibiting sepsis B) The client's temperature has been 102 *F (38.9 *C) for the last 6 hours C) The client was admitted today with a urinary tract infection D) Will you prescribe a complete blood count to check the white blood cell count and a culture?
D) Will you prescribe a complete blood count to check the white blood cell count and a culture? SBAR is an acronym for Situation, Background, Assessment, Recommendation. Situation is what the nurse describes, the current situation. Background is the pertinent information regarding the current situation. Assessment is objective information that supports the situation. Recommendation is what the nurse recommends to the health care provider. In this case, the Recommendation is the nurse asking the provider to prescribe a complete blood count and culture. "I am concerned that the client might be exhibiting sepsis" is a situation statement. "The client's temperature has been 102°F (38.9°C) for the last 6 hours" is the assessment of the client supporting the situation. The client being admitted today with a urinary tract infection is Background.
The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mm Hg when all other vital signs are normal. This reflects what type of documentation? A) SOAP B) narrative C) focus D) charting by exception
D) charting by exception Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. In the scenario, the BP is abnormal and is documented by exception. The other types of documentation are not being represented in this scenario.
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: A) need to obtain legal representation to update their health records B) can be punished for violating guidelines C) are required to obtain health record information through their insurance company D) have the right to copy their health records
D) have the right to copy their health records 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.
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? A) I am calling because the client receiving blood has developed dyspnea and had crackles B) this client has a medical history of heart failure C) it seems like this client has fluid volume overload D) i think the client would benefit from intravenous furosemide
D) i think the client would benefit from intravenous furosemide Situation, background, assessment, and recommendations (SBAR) provides a consistent method for hand-off communication that is clear, structured, and easy to use. The S (situation) and B (background) provide objective data, whereas the A (assessment) and R (recommendations) allow for presentation of subjective information. Calling to report dyspnea and crackles occurs as the nurse describes the situation. Providing the medical history occurs as the nurse offers important background information. Stating that the client has fluid volume overload is the assessment of the nurse. Stating that the nurse thinks the client would benefit from intravenous furosemide is the nurse's recommendation.
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? A) source-oriented method B) PIE charting C) focus charting method D) problem-oriented method
D) 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. Progress notes clearly focus on client problems. 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, health care providers, laboratory, x-ray personnel, and so on. Notations are entered chronologically. 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). Focus charting method brings the focus of care back to the client and the client's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a client and client care.
A nurse at a community-health center is completing an audit of client records. The outcomes of this project will serve what set of purposes? A) communication and evaluation B) knowledge and advocacy C) education and confidentiality D) quality assurance and reimbursement
D) quality assurance and reimbursement Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits are not normally used for communication or advocacy purposes. Though confidentiality would need to be maintained, this is not the purpose of the exercise.
A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator? A) talking directly to the translator facilitates the transfer of information B) talking loudly helps the translator and the client understand the information better C) it is always okay to not use a translator if a family member can do it D) translators may need additional explanations of medical terms
D) translators may need additional explanations of medical terms When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times.