Ch 3 Foundation EAQ Documentation

Which information is important for the nurse to document in the medical record when transferring a patient? Proof of insurance coverage Health care provider's prescription on record Time leaving and mode of transportation Which family members are accompanying a patient

Time leaving and mode of transportation

A health care facility uses problem-oriented medical record (POMR) charting for documenting patient records. The new nurse manager feels that the word "problem" can carry negative connotations. Which charting method would the nurse manager suggest as an alternative, keeping in mind that minimal structural change can be made? Narrative charting Charting by exception Clinical (critical) pathways Focus charting

Focus charting

Which component of the health care record must a patient receive before being released from a medical facility? Nurses' notes Progress notes Discharge summary History and physical examination section

Discharge summary

Which document would the nurse manager check to verify a patient's progress? Consultation sheet Admission form Flow sheet Ancillary staff sheet

Flow sheet

Which statement demonstrates the assessment portion of SBAR documentation? "Mr. Jones has a prothrombin time of 30 seconds with an international normalized ratio (INR) of 3.0." "Mr. Jones presents with epistasis and significant bruising to the arms." "Mr. Jones has been receiving warfarin (Coumadin) 5 mg by mouth every evening." "This is the nurse caring for Mr. Jones. I am calling you about his prothrombin time and INR."

"Mr. Jones presents with epistasis and significant bruising to the arms."

When charting using the SOAPE model, which entry would be documented under the "S" portion of the model? "Nurse to continue to measure wound once a week." "Dressing changed with sterile 4 × 4 wrapped with gauze." "Patient reports pain level of 8 out of 10 during dressing changes." "Use sterile normal saline to loosen dressings before removal."

"Patient reports pain level of 8 out of 10 during dressing changes."

Which finding in a patient's medical record indicates the need for staff education on proper documentation practices? "Status is unchanged." "Consumed 75% of breakfast." "Reports feeling fatigued today." "Ambulated the hall three times."

"Status is unchanged."

During an audit, the nurse manager observes that the nursing notes in several charts were lengthy and irrelevant. Which strategies would the nurse manager teach the staff to use to improve charting quality? Select all that apply. Use approved abbreviations. Replace words with their synonyms. Reduce the amount of information. Use standard symbols and acronyms. Shorten sentences to matter-of-fact statements. Remove all the medical terms and jargon used.

- Use approved abbreviations. - Use standard symbols and acronyms. - Shorten sentences to matter-of-fact statements.

Which action is considered inappropriate documentation? Select all that apply. -Failure to record a patient fall -Charting a medication before it is given -Charting an assessment before it is performed -Failure to chart the correct time an event occurred -Using approved abbreviations while charting nurse's notes

-Failure to record a patient fall -Charting a medication before it is given -Charting an assessment before it is performed -Failure to chart the correct time an event occurred

Which finding during review of nursing documentation indicates the need for staff education? Select all that apply. Leaving spaces between narrative entries in the medical record Drawing a line through an erroneous entry with initials, date, and time Charting abbreviations and medical terminology not on an approved list Using direct quotes when reporting what a patient has stated to the nurse Documenting that a health care provider refused to change inappropriate prescription

-Leaving spaces between narrative entries in the medical record -Charting abbreviations and medical terminology not on an approved list -Documenting that a health care provider refused to change inappropriate prescription

Which documentation guideline would the nurse use while documenting in the patient's records? Select all that apply. - Common abbreviations can be used in documentation. -Document errors can be rectified by using correction fluids. -Only hard-pointed, permanent black ink pens would be used. -Only the patient findings that have been observed by the nurse would be documented. -Such phrases as "status unchanged" or "had good day" would not be used.

-Only hard-pointed, permanent black ink pens would be used. -Only the patient findings that have been observed by the nurse would be documented. -Such phrases as "status unchanged" or "had good day" would not be used.

When is the best time for a nurse to document patient care? When the patient does not have care needs As soon as possible after completion of care Only when patient response to care needs to be documented At the end of the shift after all patient care needs have been met

As soon as possible after completion of care

The nurse is unable to insert an intravenous (IV) line and asks a coworker to complete the insertion. Which action would the nurse perform after the coworker has inserted the IV? Remove the previous IV line. Ask the coworker to document the IV line insertion. Document that the IV line was inserted by the other nurse. Request the nurse manager document the insertion.

Ask the coworker to document the IV line insertion.

Which action would the nurse take when documenting? Clearly indicate goal-directed nursing care Minimize nursing notes to address priority nursing problems Provide information about adverse events that occur throughout the day Document subjective information provided by the patient, but not objective information

Clearly indicate goal-directed nursing care

When collecting a patient's valuables before surgery to be turned over to security for safekeeping, which statement would be included in the documentation accompanying the items? 2-carat diamond ring Two gold-plated sapphire earrings Designer purse with wallet and key ring Gold-colored smart watch with white band

Gold-colored smart watch with white band

Which statement from the nurse regarding documentation requires correction? "I should document in the patient's medical record with red ink." "I should allow myself plenty of time to perform my documentation." "I should never leave the patient's medical record open on the desk." "I should use quotation marks when documenting a patient's statements."

I should document in the patient's medical record with red ink."

The primary health care provider instructs the licensed practical nurse/licensed vocational nurse (LPN/LVN) to medicate a patient if the patient's body temperature rises above 102°F (38.9°C). In which section would the LPN/LVN record the information, using the SOAPIER documentation format? Objective Evaluation Assessment Intervention

Intervention

A patient with an abnormal laboratory value had discharge orders. The nurse assessed the patient and called the primary health care provider for a prescription. The nurse read the phone prescription back to the primary health care provider and verified the dosage. Which tool did the nurse use to prevent a medication error caused by communication? Focused charting Charting by exception (CBE) Problem-oriented charting Introduction, Situation, Background, Assessment, Recommendation, Read Back (ISBARR)

Introduction, Situation, Background, Assessment, Recommendation, Read Back (ISBARR)

While accessing a patient's data using an electronic health record, the nurse is called away from the station. Which action would the nurse take before leaving the station? Ask the manager to wait. Log off of the computer. Ask a colleague to help. Shut down the computer.

Log off of the computer.

Which action by the nursing student requires correction regarding patient confidentiality? Change computer passwords regularly. Shred papers that have identifying patient information. Make copies of medication lists to review privately at home. Log out of computer systems when leaving workspaces unattended.

Make copies of medication lists to review privately at home.

Which method of patient charting is created from assessment findings? Case management system charting Focus charting Problem-oriented medical record (POMR) charting Narrative charting

Narrative charting

The nurse manager audits whether nursing care provided to patients adheres to accepted standards. Which part of the documentation would be reviewed? Primary health care provider's prescriptions Progress sheet Consultation sheet Nurse's notes

Nurse's notes

When caring for a patient with pneumonia, which information would the nurse refrain from documenting in the patient's chart? Patient is not listening to information. Patient has shortness of breath on exertion. Patient requires a walker for ambulation. Patient refuses to use incentive spirometer.

Patient is not listening to information.

If unsure about how to abbreviate, how would a nurse approach using abbreviations in documentation? Chart using the abbreviations learned in school. Ask the other nurses on the unit what is accepted. Refer to the facility's published list of abbreviations. Use any form of abbreviations, as long as they can be recalled in a legal situation.

Refer to the facility's published list of abbreviations.

While documenting in the progress notes, the nurse updates only the data and action components. Which component of the focus charting system did the nurse's documentation neglect? Implementation Assessment Discharge details Response

Response

Which acronym represents the approach of documenting implementation and evaluation in the patient progress notes? SOAP SOAPIE SOAPIER SOAPI

SOAPIER

Which action would the nurse take when documenting in a patient's electronic medical record and the health care provider requests that the nurse make rounds? Complete the current documentation. Save the data and log out of the computer. Request a different nurse to make the rounds. Leave the computer and complete the rounds.

Save the data and log out of the computer.

Which action does the nurse take regarding a patient's chart after discharge? Release it to the family. Give it to the manager. Send it to the medical records room. Send it home with the patient.

Send it to the medical records room.

Which document would help the nurse gather information from the previous shift? Personal health record (PHR) Problem-oriented medical record (POMR) Medication administration records (MARs) Situation, Background, Assessment, and Recommendation (SBAR)

Situation, Background, Assessment, and Recommendation (SBAR)

Which finding indicates the need for additional staff education regarding documentation? Using correction fluid to fix errors Charting completed throughout shifts Documenting time and date of entries Verbally clarifying the health care provider's orders

Using correction fluid to fix errors