CH 19 - DOCUMENTATION PREP U
Which pieces of information should the nurse treat as confidential and not disclose? Select all that apply. A deceased client's history for organ donation A client's address A client's Social Security number Information about a client's past health conditions A client's diagnosis linked to a disease outbreak
A client's Social Security number Information about a client's past health conditions A client's address
A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines?
Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth Explanation: Nursing documentation should focus on behaviors and avoid words such as better, normal, or worse. Using terms such as "inappropriate behavior" or "belligerent" is judgmental. The nurse should document only actual behaviors that the nurse witnesses.
A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?
Nurse case manager Explanation: The nurse case manager is the expert on resources available for the client's care. The nurse manager is responsible for the operation of the nursing unit. The physician is concerned with the client's medical needs. The insurance company is a possible resource, if the client has insurance coverage.
A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? Place the narrative note chronologically after the respiratory therapist's note. Review the laboratory results under the physician section. Use a critical pathway to document the physical assessment. Write a narrative note in the designated nursing section.
Write a narrative note in the designated nursing section. Explanation: Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the physician section. Critical pathways are not used to document physical assessments.
What dual purpose does an audit serve? education and confidentiality communication and evaluation quality assurance and reimbursement knowledge and quality
quality assurance and reimbursement Explanation: Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits have no role in communications, evaluation, knowledge, quality, education, or confidentiality,
A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis? the client's employer the public health department Health Canada the client's family
the public health department Explanation: Notifying the public health department of communicable disease is considered an exemption for beneficial disclosure. Health Canada is not involved in individual incidences of illness. The client's employer is not privy to the information for confidentiality reasons.
The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client?
Inform the client what to expect after the surgery. Explanation: If the surgery is an emergency, the highest priority is to meet the client's immediate needs. The nurse should inform the client about what to expect after surgery. Discussing discharge plans, instructing in wound care, and teaching about dietary restrictions are important, but not necessary before the surgery.
A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? "I am calling because the client receiving blood has developed dyspnea and had crackles." "This client has a medical history of heart failure." "I think the client would benefit from intravenous furosemide." "It seems like this client has fluid volume overload."
"I think the client would benefit from intravenous furosemide." Explanation: 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 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? "The client had a good deal of anxiety last night and requested to be turned and repositioned frequently." "No medical issues overnight that require immediate attention." "The unlicensed assistive personnel turned the client every 2 hours last night, but the client should continue to be repositioned during the day." "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."
"The client had a good deal of anxiety last night and requested to be turned and repositioned frequently." Explanation: 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.
Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records?
"The clients' medical records are an obstruction to research and education." Explanation: The clients' medical records are good sources of data for research and education, and, therefore, it is incorrect to say that they are an obstruction. The other statements do not need correction.
The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client? 0800: Resting in bed, eating some breakfast. Complains of headache. 0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. 0800: Side rails up, call light in reach. Bed in high position. 8:00: Pt is resting in bed and appears to be comfortable.
0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. Explanation: Pt is not an appropriate abbreviation for patient and it is understood that all entries are specific to the patient. Avoid the phrases "appears to be" and "seems to be," as they suggest uncertainty. Military time should be used to avoid confusion. Specific, detailed information should be included when possible, such as consumed 80% of breakfast and a reported pain level. Bed in high position is not appropriate for patient safety.
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 sentinel event An audit A never event A variance
A variance Explanation: 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 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.
After introductions, the nurse states the client name, room number, and problem. The nurse states that the client's condition "could be life-threatening." The nurse reads back the physician's new orders at the conclusion of the call.
The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? Assess the client's response to the ambulation. Discuss the client's feelings about the illness. Document the client's ambulation. Inform the client when ambulation is scheduled next.
Assess the client's response to the ambulation. Explanation: After a nurse has performed an intervention, the next step is to evaluate the effectiveness of the intervention. The nurse should assess the client's response to the ambulation. Informing the client when ambulation is scheduled next, discussing the client's feelings, and documenting the ambulation are important, but not until after the client has been reassessed.
A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation? Attach a copy of the incident report to the chart. Stop the infusion and document the time. Report the error to the primary provider. Fill out an incident report.
Attach a copy of the incident report to the chart. Explanation: For legal reasons, the nurse should not attach a copy of the incident report to the chart. The nurse should, however, stop the infusion and document the time, report the error to the primary provider and nursing supervisor, and fill out an incident report.
Which agency is responsible for monitoring compliance to Health Information Technology for Economic and Clinical Health (HITECH)? Department of Social Services The Joint Commission Centers for Medicare and Medicaid Services World Health Organization
Centers for Medicare and Medicaid Services Explanation: The HITECH Act was established in 2009 to create incentives for professionals and agencies to receive financial payment for the meaningful use of technology to improve client care. The Centers for Medicare and Medicaid Services is the agency responsible for monitoring compliance to HITECH. The Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States. The World Health Organization is a specialized agency of the United Nations that is concerned with international public health. There is a department of social services in each state that focuses on benefits and facilities such as education, food subsidies, health care, police, fire service, job training and subsidized housing, adoption, community management, policy research, and lobbying.
Which note includes all elements of a SOAP note?
Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness. Explanation: 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 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? Care plan and client's record Occurrence report and critical pathway Critical pathway and care plan Client's record and occurrence report
Client's record and occurrence report Explanation: 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.
What is the primary purpose of the client record? Education Communication Research Advocacy
Communication Explanation: Patient records serve many purposes., but the ANA states that the most important of these is "communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory and legislative, reimbursement, research, and quality activities" (ANA, 2010, p. 5). Thus communication with the health care team is a more important purpose of documentation than advocacy, research, or education.
The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do? Delay the instruction until the visitors leave. Ask the client if the client has any questions. Give the visitors instructions to leave in 10 minutes. Leave written information for the client to read later.
Delay the instruction until the visitors leave. Explanation: The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is a teenager and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors leave. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information.
Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which?
Finances of the client Explanation: The client's condition, time and resources, and feedback or input from the family are all of great value when the nurse is prioritizing the client's nursing diagnoses. The client's finances, however, should not influence the nurse's priority setting. The nursing code of ethics states that clients should receive the same treatment regardless of their ability to pay.
Which is an independent (nurse-initiated) action?
Helping to allay a client's fears about surgery Explanation: An independent (nurse-initiated) action is one that a nurse may initiate and carry out independently, without an order from a physician or any other health care provider. Helping the client decrease fear about surgery by answering questions or arranging a meeting with the surgeon is an independent nursing intervention. Interventions that involve executing a physician's orders, such as for catheterization and medication administration, are dependent nursing interventions. Meeting with other health care professionals describes collaborative care.
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? Call the pharmacy to have the order entered in the electronic record. Add the new order to the medication administration record. Inform the health care provider that a written order is needed. Write the order in the client's record.
Inform the health care provider that a written order is needed. Explanation: 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.
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 records progress under problems, intervention, and evaluation. It provides quick access to abnormal findings. It documents assessments on separate forms. It provides and refers to a client's problem by a number.
It provides quick access to abnormal findings. Explanation: Charting by exception (CBE) provides quick access to abnormal findings, as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.
Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing? Nutritional consult Podiatry referral Social services consult Pulmonologist referral
Nutritional consult Explanation: A nutritional consult would be most appropriate for this situation. Social services, a pulmonologist, or a podiatrist would not be effective to improve the client outcomes.
Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. Keeping record of people who have access to clients' records Posting information linking a client with diagnosis, treatment, and procedure on whiteboards 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 Making the names of clients on charts visible to the public
Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records
A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse best reflects the effectiveness of the pain medication?
Rates pain 8/10, states nauseated for last 30 minutes. Explanation: 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.
The nurse receives a verbal prescription from a health care provider during an emergency situation. Which action(s) should be taken by the nurse? Select all that apply. Read back the prescription. Have the health care provider review and sign the prescription during the emergency. Record the prescription on the pharmacy discrepancy sheet. Include V.O. with the health care provider's name on the prescription. Record the date and time of the prescription.
Read back the prescription. Record the date and time of the prescription. Include V.O. with the health care provider's name on the prescription.
Which actions should the nurse take before making an entry in a client's record? Select all that apply. Checking that clients' names are not identified within the chart forms Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting Choosing the charting format that the nurse prefers Reviewing the agency's list of approved abbreviations
Reviewing the agency's list of approved abbreviations Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting
Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? Continue assisting the client to the bathroom to ensure the client's safety. Revise the care plan to allow the client to ambulate to the bathroom independently. Consult with the physical therapist to determine the client's ability. Instruct the client's family to assist the client to ambulate to the bathroom.
Revise the care plan to allow the client to ambulate to the bathroom independently. Explanation: The intervention of assisting the client to the bathroom is no longer indicated, so the nurse would appropriately revise the care plan to discontinue that intervention. A consult with a physical therapist is not necessary to verify the nurse's independent assessment. If the client is safe to ambulate to the restroom independently, it is not necessary for the family to assist.
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. R: The nurse explains the rules of the new facility to the client. 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 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.
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.
As part of a client's plan of care, a nurse teaches a client's spouse how to perform a dressing change to the client's abdominal wound. Which method would be most effective to determine whether the spouse has mastered the skill? Spouse lists the signs of healing. Spouse performs the steps of the dressing change correctly. Spouse identifies the steps for the dressing change. Spouse shows the nurse what supplies are needed.
Spouse performs the steps of the dressing change correctly. Explanation: The only way to be sure that clients or family caregivers have mastered a skill is watching them perform it. Once the nurse observes them doing a procedure correctly, the nurse can be confident that learning—as well as teaching—has occurred. The other answer options only demonstrate that the spouse has learned the cognitive aspects to related to the skill; the spouse can only demonstrate full, effective knowledge of the skill by performing it. Reference
Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information Submitting a written notice to all clients identifying the uses and disclosures of their health information Releasing the client's entire health record when only portions of the information are needed Disclosing client health information for research purposes after obtaining permission from the client's physician
Submitting a written notice to all clients identifying the uses and disclosures of their health information Explanation: 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 physician'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.
The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention? Surveillance Supportive Collaborative Maintenance
Surveillance Explanation: Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Maintenance nursing interventions involve the nurse assisting the client with performing routine activities of daily living. Supportive nursing measures involve providing basic comfort and emotional care to the client. Collaborative nursing interventions involve coordination and communication with health care professionals in other fields to meet the client's needs.
The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent? The parents have comprehensive insurance coverage for their family's medical care. The client expresses a desire to learn how to manage the medication regime. The parents verbalize acceptance of the need to closely monitor their child's condition. The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.
The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. Explanation: If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the education. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan.
The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? The client appears to have a low tolerance for pain and frequently reports intense pain. The client reports that on a scale of 0 to 10, the current pain is a 3. The client appears comfortable and is resting adequately and appears to not be in acute distress. The client is receiving sufficient relief from pain medication, stating no pain in either knee.
The client reports that on a scale of 0 to 10, the current pain is a 3. Explanation: The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.
The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? The client is coughing and experiencing severe heartburn in the morning. The client has a history of severe complaints in the morning. The client has symptoms in the morning associated with a heart attack. The client reports waking up this morning with a severe headache.
The client reports waking up this morning with a severe headache. Explanation: 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.
A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? The abdominal area The lower extremities Lung sounds Heart rate and rhythm
The lower extremities Explanation: 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 nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider?
The nurse can accept verbal orders to provide immediate care and record once the client is stable. Explanation: In most agencies, the only circumstance in which the attending physician, nurse practitioner, or house office may issue orders verbally is in a medical emergency. In such a situation, the physician/nurse practitioner is present but finds it impossible to write the order due to the emergency circumstances. When a client is admitted to the unit, the prescriber writes orders either in the electronic record or on paper. Physicians/providers can insert orders remotely, but this is not the most appropriate option in an emergency. Stabilization of the client, while important, should not supersede receiving orders as the providers instructions could be integral to stabilizing the client.
The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? The nurse can implement care once written orders are received from the provider. The nurse can accept verbal orders to provide immediate care and record once the client is stable. The client must be stabilized before the nurse can obtain any orders from the provider. The provider can input orders remotely into the EHR system for the nurse to retrieve.
The nurse can accept verbal orders to provide immediate care and record once the client is stable. Explanation: In most agencies, the only circumstance in which the attending physician, nurse practitioner, or house office may issue orders verbally is in a medical emergency. In such a situation, the physician/nurse practitioner is present but finds it impossible to write the order due to the emergency circumstances. When a client is admitted to the unit, the prescriber writes orders either in the electronic record or on paper. Physicians/providers can insert orders remotely, but this is not the most appropriate option in an emergency. Stabilization of the client, while important, should not supersede receiving orders as the providers instructions could be integral to stabilizing the client.
While assisting a client with a delivery, a nurse takes a photo of the newborn and posts it on a social media website. What action may occur related to this privacy violation? No action will be taken as long as the parents don't find out. The nurse could be fined or even go to jail for violating HIPAA. There will be no repercussions if the nurse takes the photo down from the social media page. The nurse could be fired but would not face criminal charges or jail time.
The nurse could be fined or even go to jail for violating HIPAA. Explanation: The nurse has committed a HIPAA violation and most likely breached the facility's social media policy. The nurse has placed a newborn and family at risk by posting photos to a social media website where anyone is at liberty to view the page. The nurse may well be dismissed for this infraction and is at risk for fines and imprisonment for a HIPAA violation, even if the nurse takes the photo down and the parents do not find out. The managers at the facility should enforce the social media policy, explain violations and consequences to all staff, and have them sign the social media policy.
Which are purposes of documentation in health care records? Select all that apply. To serve as a financial record To provide personal communication to the family To facilitate quality To support decision analysis To assist with clinical research
To facilitate quality To serve as a financial record To support decision analysis To assist with clinical research
Which is not a purpose of the client care record? To assist with care planning To facilitate reimbursement To serve as a contract with the client To serve as a legal document
To serve as a contract with the client Explanation: 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 was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy? Refer the insurance agency directly to the client. Do not release any information to the insurance company. Use minimum disclosure policy to release the information. Release the full medical record to expedite payment.
Use minimum disclosure policy to release the information. Explanation: The nurse should use minimum disclosure policy to release the information, as per HIPAA regulations. It is inappropriate to not release any information to the insurance company, to refer the insurance agent directly to the client, and to release the full medical record to expedite payment.
Which strategy would provide the most effective form of change of shift report? Discussing the client's visitors and complaints during the prior shift. Recording the report for the oncoming shift prior to leaving the unit. Utilizing a reporting form and allowing time for any questions. Providing the oncoming nurse the client's clipboard prior to leaving the unit.
Utilizing a reporting form and allowing time for any questions. Explanation: A change-of-shift report is a discussion between health care team members leaving their shift and health care team members coming on duty for the next shift. It includes a summary of each client's condition and current status of care and should be in a standardized format to ensure concise and accurate information. It is not useful to discuss the client's complaints and visitors during the prior shift. Tape recording and giving the nurse the client's clipboard doesn't allow the oncoming nurse to ask questions.
Which documentation by the nurse best supports the PIE charting system?
Vomiting 250 mL undigested food, antiemetic given, no further vomiting Explanation: 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).
Which documentation tool will the nurse use to record the client's vital signs every 4 hours? acuity charting forms a 24-hour fluid balance record a medication record a flow sheet
a flow sheet Explanation: A flow sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special needs.
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: reporting. a referral. a consultation. conferring.
a referral. Explanation: 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.
The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation? charting by exception narrative focus SOAP
charting by exception Explanation: 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.
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? FOCUS data, action, and response note narrative notes charting by exception problem, intervention, and evaluation note
charting by exception Explanation: 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 reflect a possible problem area but does not need to be an actual problem. Reference:
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? variance charting charting by exception (CBE) FOCUS charting problem, intervention, evaluation (PIE) charting
charting by exception (CBE) Explanation: 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 the narrative notes. Charting by exception decreases charting time. FOCUS charting does not use a problem list of nursing or medical diagnoses, but incorporates many aspects of the client and client care into a FOCUS column. The focus may be a client strength, problem, or need. Problem, intervention, evaluation (PIE) charting incorporates the plan of care into the progress note, and problems are identified by an assigned number. Variance charting is used when clients fail to meet an expected outcome, or when a planned intervention is not implemented in the case management model.
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:
have the right to copy their health records. Explanation: 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.
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: limiting abbreviations to those approved for use by the institution. ensuring that abbreviations are understandable to clients who may seek access to their health records. using only abbreviations whose meaning is self-evident to an educated health professional. using only those abbreviations that are defined in full at another location in the client's chart.
limiting abbreviations to those approved for use by the institution. Explanation: 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.
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? data base plan of care progress notes problem list
progress notes Explanation: 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.
A client's record can be more accurate if the nurse:
uses point-of-care documentation. Explanation: 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.
