Ch 19 documenting and reporting
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? Critical pathway and care plan Client's record and occurrence report Occurrence report and critical pathway Care plan and client's record
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 is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? "I am sorry I can't access that information." "The provider will need to give permission for you to review." "Let me get that for you." "Only authorized persons are allowed to access client records."
"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 nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? Verification Reporting Documentation Dialogue
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 Share Point 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.
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? progress notes plan of care data base problem list
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.
The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states: The use of rationales is not commonly practiced in the clinical setting. Although not written, the nurse must know or question the rationale before performing an action. Rationales are only important while the nurse is in training. The rationale is deleted to provide additional charting space in the computer system. Some facilities do not require them on their plans of care.
Although not written, the nurse must know or question the rationale before performing an action. Although the scientific rationale is not documented in the clinical plan, it is no less important than in the instructional plan. Nurses and other members of the healthcare team must know the rationale behind the intervention or must question and review the rationale before performing the action.
According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? Accreditation Documentation Psychomotor skills Clinical judgment
Documentation Documentation is the primary source of evidence used to measure performance outcomes, according to the CNA. Accreditation is the process whereby educational institutions are evaluated and, if approved, certified by a third party to validate their competency. Psychomotor skills are skills that require physical actions and muscular coordination to perform. Clinical judgment is an attribute of health care professionals that involves the use of critical thinking, intuition, and clinical experience when making a decision about a client's care to achieve the best outcome for the client.
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 consultation. conferring. reporting. a referral.
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.
The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? Access the health care record at the bedside and show the client how to navigate the electronic health record. Discuss how the hospital can be fined for allowing clients to view their health care records. Explain that only a paper copy of the health care record can be viewed by the client. Review the hospital's process for allowing clients to view their health care records.
Review the hospital's process for allowing clients to view their health care records. The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the records.
Besides being an instrument of continuous client care, the client's health care record also serves as a(an): Kardex. assessment tool. incident report. legal document.
legal document. The client record serves as a legal document of the client's health status and care received. An assessment tool may be a formal document that is included as part of the client's record. A Kardex is typically an erasable, temporary document that would be shredded when no longer needed for the client's care. Incident reports are internal documents that are not a part of the client's record, and therefore not a legal document regarding their health care.
The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? organization objectivity reimbursement subjectivity
subjectivity Quoting what the client is saying helps in the documentation of subjective data. Objective data are assessment data that may be directly observed by the nurse such as blood pressure. Organization is the structure of the documentation and does not relate to subjective data. Reimbursement is a distractor that doesn't relate to assessment data.
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? Document the UAP's conversation. Report the UAP to the nurse manager. Notify the client relations department about the breach of privacy. Remind the UAP about the client's right to privacy.
Remind the UAP about the client's right to privacy. The nurse should first remind the UAP about the client's right to privacy. All other actions are appropriate, but do not immediately protect the client's privacy.
A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response? "HIPAA legislation allows for you to change any information." "HIPAA legislation only allows access to review the medical record." "According to HIPAA, medical records cannot be changed." "According to HIPAA legislation, you have a right to request changes to inaccurate information."
"According to HIPAA legislation, you have a right to request changes to inaccurate information." The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records. They may also update their health record if inaccurate, get a list of the disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations, request a restriction on certain uses or disclosures, and choose how to receive health information.
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? "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family." "You may continue to post about a client, as long as you do not use the client's name." "Any information that can identify a person is considered a breach of client privacy." "All aspects of clinical practice are confidential and should not be discussed."
"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.
A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse? "It would be easier to do it that way. You could develop a tool to use." "Legal policy requires nursing practice to be permanently integrated into the client record." "The electronic health record we use does not allow us to use different formats." "The facility requires us to document client care this way because of the computer application used."
"Legal policy requires nursing practice to be permanently integrated into the client record." Legal policy requires nursing care documentation to be permanently integrated into the client record. Computer applications and electronic health record formats may have some differences, but they all use an integrated record. Suggesting that the nurse develop a new tool would be inappropriate, as separate nursing documentation would not be legal.
Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A client has asked a nurse if he can read the documentation that his physician wrote in his chart. A client who resides in Indiana has required hospitalization during a vacation in Hawaii. A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test.
A client has asked a nurse if he can read the documentation that his physician 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.
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? Take the parent to the client's room and have the client give the requested information. Explain the reasons for the hospitalization, but give no further information. Ask the client if information can be given to the parent. Provide the information to the parent.
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.
Which note includes all elements of a SOAP note? Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. Client reports nausea, vomiting, and diarrhea × 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. 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.
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? Client states expecting some pain, but it is more severe than anticipated. Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. Client is requesting pain medications, is grimacing, and is diaphoretic.
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.
Which are appropriate actions for protecting clients' identities? Select all that apply. Place light boxes for examining X-rays with the client's name in private areas. Ensure that clients' names on charts are visible to the public. Document all personnel who have accessed a client's record. Have conversations about clients in private places where they cannot be overheard. Orient computer screens toward the public view.
Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. 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 patient confidentiality.
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. Write the order in the client's record. Inform the health care provider that a written order is needed. Add the new order to the medication administration record.
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.
The nurse cared for a client admitted with uncontrolled hypertension. The client suffered a stroke shortly after the nurse's shift ended. Which information will determine if the nurse is liable? Omitting documentation of blood pressure at the end of the shift Failure to administer aspirin, as the client reported taking it at home Administering acetaminophen for report of headache Relaying report of nausea to the health care provider
Omitting documentation of blood pressure at the end of the shift Legal cases have been argued with the principle that "if it was not documented, it was not done." For this reason, it is important to document normal, as well as abnormal findings. Because nurses and other health care team members cannot remember specific assessments or interventions involving a client years after the fact, accurate and complete documentation at the time of care is essential. Failure to administer aspirin or the administration of acetaminophen would have been documented in the health record. Relaying a report of nausea would not have made the nurse liable for the client's status. Communication in the health record, as well as a report at shift change, is a vital part of nursing.
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 symptoms in the morning associated with a heart attack. The client reports waking up this morning with a severe headache. The client has a history of severe complaints in the morning.
The client reports waking up this morning with a 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.
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: have the right to copy their health records. are required to obtain health record information through their insurance company. need to obtain legal representation to update their health records. can be punished for violating guidelines.
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.
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: important information. relevant data. interpretation of data. factual statement.
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.
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? "It seems like this client has fluid volume overload." "This client has a medical history of heart failure." "I think the client would benefit from intravenous furosemide." "I am calling because the client receiving blood has developed dyspnea and had crackles."
"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 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? "I will have to review the policy that determines what procedure is in place for client access." "The hospital owns your records and does not have to allow you access while you are a client here." "Let me open up the computer access so that you can see what information is of interest to you." "You may not understand all of the information and it will confuse you so I will help you decipher it all."
"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.
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? "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." "Vital signs do not need to be recorded unless they are abnormal." "The UAP is able to log in and enter the information so all members of the health care team can see it." "The UAP logs in under my name and documents the vital signs."
"The UAP is able to log in and enter the information so all members of the health care team can 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.
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? "I am concerned that the client might be exhibiting sepsis." "The client was admitted today with a urinary tract infection." "The client's temperature has been 102°F (38.9°C) for the last 6 hours." "Will you prescribe a complete blood count to check the white blood cell count and a culture?"
"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 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? "The client was admitted today with a urinary tract infection." "I am concerned that the client might be exhibiting sepsis." "The client's temperature has been 102°F (38.9°C) for the last 6 hours." "Will you prescribe a complete blood count to check the white blood cell count and a culture?"
"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 tasked to organize weekly care plan conferences with other health care team members. Which would be appropriate items to include in this meeting? Select all that apply. A discussion of the meal plan for a client with diabetes A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made A conversation addressing the need for durable medical equipment when the client goes home A review of a client's current progress in the plan of care A recommendation for pain management by the emergency department physician who admitted the client a week ago
A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made A review of a client's current progress in the plan of care A discussion of the meal plan for a client with diabetes A conversation addressing the need for durable medical equipment when the client goes Care plan conferences are discussions about client care, usually involving several disciplines. Interdisciplinary conferences help to coordinate services so that the client's plan of care can be developed and implemented in the most efficient way. Nurses may initiate these conferences and invite members of the health care team from other departments (e.g., physical therapy, social services, dietary). Clients who most benefit from such conferences are those with multiple, complex problems. The emergency physician is no longer needed to address care provided in the health care facility.
The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report? Transfer report Nurse's shift report Incident report Telemedicine report
An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.
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 and refers to a client's problem by a number. It provides quick access to abnormal findings. It documents assessments on separate forms.
It provides quick access to abnormal findings. 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 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 Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Obscuring identifiable names of clients and private information about clients on clipboards 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 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 action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? Identifying nursing diagnoses or clients' needs Documenting clients' health histories and discharge planning Omitting clients' responses to nursing interventions Recording nursing interventions
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 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? Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. 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. Problem-oriented recording gives clients the right to withhold the release of their information to anyone. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers.
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.
The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? Access the health care record at the bedside and show the client how to navigate the electronic health record. Review the hospital's process for allowing clients to view their health care records. Explain that only a paper copy of the health care record can be viewed by the client. Discuss how the hospital can be fined for allowing clients to view their health care records.
Review the hospital's process for allowing clients to view their health care records. The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the records.
Which actions should the nurse take before making an entry in a client's record? Select all that apply. Reviewing the agency's list of approved abbreviations Locating clients' files within an electronic health record system Choosing the charting format that the nurse prefers Identifying the form appropriate to be used for documenting Checking that clients' names are not identified within the chart forms
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 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 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 reports that on a scale of 0 to 10, the current pain is a 3. The client appears to have a low tolerance for pain and frequently reports intense pain. 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. 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 reports waking up this morning with a severe headache. The client has symptoms in the morning associated with a heart attack. The client has a history of severe complaints in the morning.
The client reports waking up this morning with a 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.
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. identifying demographics, including diagnosis current orders any abnormal occurrences with the client during the shift what time the nurse will return for the next shift what the client watched on television during the shift
any abnormal occurrences with the client during the shift identifying demographics, including diagnosis 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 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? protecting the nurse and the hospital from litigation identifying risks and ensuring future safety for clients gauging the nurse's professional performance over time following up the incident with other members of the care team
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.
