345 Test #3 Chp 19 Documenting + Reporting

What are the 5 characteristics of effective documentation

Factual Accurate Complete Current Organized

In SBAR, what does R stand for? Reinforcing data Response Recommendations Report

Recommendations

A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply. S: The nurse handling the transfer describes the client situation to the new nurse. S: The nurse discusses the client's symptoms with the new nurse in charge. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse explains the rules of the new facility to the client. R: The nurse gives recommendations for future care to the new nurse in charge.

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

Record Documentation that is organized around patient problems rather than sources of information, and the entire health care team works together to develop care plan is what? a. problem oriented b. source oriented c. pie charting d. focus charting

a

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. Inform the health care provider that a written order is needed. b. Write the order in the client's record. c. Call the pharmacy to have the order entered in the electronic record. d. Add the new order to the medication administration record.

a

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. "Only authorized persons are allowed to access client records." c. "The provider will need to give permission for you to review." d. "I am sorry I can't access that information."

b

A nurse is wanting daily continuity care documented at the beginning of every shift, but does not want the hassle of having a new separate care plan. What documentation is this called? a. problem oriented b. source oriented c. pie charting d. focus charting

c

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the health care provider's order sheet. What is the nurse's BEST response? a. State: "Thank you for taking care of this! I'll be happy to document the order on the health care provider's order sheet. b. "Get a second nurse to listen to the order, and after writing the order on the health care provider order sheet, have both nurses sign it. c. State: "I am sorry, but VOs can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly. d. "Try calling another resident for the order or wait until the next shift.

c

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. plan of care d. progress notes

d

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

This type of documentation focuses charting on the holistic emphasis on the patient and the patient's priorities and patient CONCERNS a. problem oriented b. source oriented c. pie charting d. focus charting

d

A patient asks what is the purpose of keeping up with all his records during admissions. What is the primary purpose? a. diagnostic b. care planning c. quality process d. communication

d- all the others are also reasons why but communication is the primary reason

What patient information is confidential? a. name b. address c. phone d. reason patient is sick e. ALL information

e

What are the 4 P's?

pain, personal needs, positioning, fall prevention

True or False The more seriously ill, the greater need to keep information current

true

The nurse is using the ISBARR format to report a surgical client's deteriorating condition to a health care provider. Which actions would the nurse perform when using this guide? Select all that apply. a. The nurse asks the health care provider to describe the admitting diagnosis of the client. b. After introductions, the nurse states the client name, room number, and problem. c. The nurse asks the health care provider to estimate the discharge date for the client. d. The nurse asks the health care provider to comment on the present situation before giving recommendations. e. The nurse states that the client's condition "could be life-threatening." f. The nurse reads back the physician's new orders at the conclusion of the call.

b e f

Which finding from a nursing audit reflects high standards for client safety and institutional health care? a. The nurse records inappropriate nursing interventions. b. The nurse fails to identify the nursing diagnoses or clients' needs. c. The nurse documents clients' responses to nursing interventions. d. The nurse fails to adequately complete data on clients' health histories and discharge planning.

c

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 me a better sense of what my workload will be today."

a

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with appendicitis. The health care provider has ordered 10-mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follow recommended guidelines? Select all that apply. a. 6/12/20 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. c. M. Patrick, RN6/12/20 0945 Morphine 10 mg administered IV Patient seems to be comfortable. d. M. Patrick, RN6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. e. M. Patrick, RN6/12/20 0945 Patient reports severe pain in right lower quadrant. f. M. Patrick, RN6/12/20 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN6/12/20 0945 g. Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN

d e g

What are the patients rights regarding their medical record?

•See and copy their health record •Update their health record •Get a list of disclosures •Request a restriction on certain uses or disclosures •Choose how to receive health information

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

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 - problem, intervention, evaluation

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 c d

What are ways in which you can ensure accurate information was effectively documented? select all that apply a. document in timely manner b. avoid using general words "good" "normal" "seems okay" c. complete before sending out d. avoid copying/pasting in EHR

b d

What is a way to prevent a potential breach of regarding computers? a. keep screen on when you walk away b. screens do not face the public c. send email to another unit d. use encryption software e. request private printer for your unit

b d e

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 gives clients the right to withhold the release 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

What is a way to prevent a potential breach of information through a cell phone? a. use personal cell phone b. ask to use another friends phone c. use a phone with built in encryption

c

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 d e

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the correct ISBARR order. a. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." b. "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." c. "You want me to discontinue the PCA pump until you see him tonight at patient rounds." d. "I am Rosa Clark, an RN working on the second floor of South Street Hospital." e. "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer." f. "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

d a e b f c

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

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 physician 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

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 physician 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

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

a

What is the reason for providing purposeful rounding? a. Promote patient safety b. gets the morning done quicker c. encourage team communication d. Allows physicians to get background e. improve staff ability to provide efficient patient care

a c e

a paper format in which each health care group keeps data on its own separate form. This consists of progress notes and narrative notes that consists of routine care, normal findings, and patient responses. What type of Record documentation is this? a. problem oriented b. source oriented c. pie charting d. focus charting

b