Ch. 19: Documenting and Reporting

The client record is utilized for many purposes. Which might be uses for the client record? Select all that apply. a. education of student nurses b. reimbursement for services c. research d. giving information over the phone when unidentified callers call the hospital unit e. education for medical students

a, b, c, e

Which organization audits charts regularly? a. The Joint Commission b. National League for Nursing c. American Nurses Association d. Sigma Theta Tau International

a. The Joint Commission

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? a. Write a narrative note in the designated nursing section. b. Place the narrative note chronologically after the respiratory therapist's note. c. Review the laboratory results under the health care provider section. d. Use a critical pathway to document the physical assessment.

a. Write a narrative note in the designated nursing section.

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

Which is a drawback to the type of documentation known as charting by exception? a. Interference with standardized assessments b. Less interdisciplinary communication c. Issues related to high-quality care should a negligence claim arise d. Increased time required to document information

c. Issues related to high-quality care should a negligence claim arise

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? a. The client is receiving sufficient relief from pain medication, stating no pain in either knee. b. The client appears comfortable and is resting adequately and appears to not be in acute distress. c. The client reports that on a scale of 0 to 10, the current pain is a 3. d. The client appears to have a low tolerance for pain and frequently reports intense pain.

c. The client reports that on a scale of 0 to 10, the current pain is a 3.

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. progress notes

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. a. "I don't feel well. I've been urinating often, and it burns when I urinate." b. Fever, possible urinary tract infection c. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. d. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

a. "I don't feel well. I've been urinating often, and it burns when I urinate." c. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. b. Fever, possible urinary tract infection d. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor

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

a. Assess the triggers from the data.

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 states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." b. Client states expecting some pain, but it is more severe than anticipated. c. Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. d. Client is requesting pain medications, is grimacing, and is diaphoretic.

a. Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? a. Remind the UAP about the client's right to privacy. b. Report the UAP to the nurse manager. c. Notify the client relations department about the breach of privacy. d. Document the UAP's conversation.

a. Remind the UAP about the client's right to privacy.