Chapter 04: Validating and Documenting Data

Which of the following examples of documentation best exemplifies sound clinical documentation practices?

"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter." Rationale: Answer C is both precise and objective, while stating the client is "anxious" in answer A is not objective. Labelling chest sounds as "abnormal" or simply describing pain as "sharp" in answers B and D both indicate a lack of detail.

The hospital where a nurse works is converting from a paper-based documentation system to a computer-based one. The nurse recognizes that which of the following are advantages of computer-based over paper-based systems? Select all that apply. -Freedom from having to satisfy legal standards -Elimination of redundant data collection by other health care team members -The increased likelihood that clients will receive life-saving treatment -Potential lowered risk of hospital-acquired infections -Ability to link the client's health record to other documents -Greater security and privacy of client's health information

-Elimination of redundant data collection by other health care team members -Increased likelihood that clients will receive life-saving treatment -Potential lowered risk of hospital-acquired infections -Ability to link the client's health record to other documents Rationale: With the advent of computer-based documentation systems, these databases can link to other documents and health care departments, eliminating repetition of similar data collection by other health team members. The use of electronic health records also increases the likelihood that clients received life-saving treatments and may lower the risk of hospital-acquired infections. Computer-based systems still must meet legal standards and do not offer greater security and privacy of the client's health information.

A nurse assesses a pregnant client in her second trimester. The nurse documents the weight of the client and notices that the client has gained 6 pounds over a week. How should the nurse validate this data?

Compare objective findings with subjective findings. Rationale :The nurse should compare the objective findings (i.e., the client's weight) with subjective findings (i.e., what the client says about her weight gain) to uncover any discrepancies. The nurse should have the client weighed again on a different scale, not the same one, to rule out equipment error. The nurse may not be able to verify the previously documented data; the nurse who conducted the assessment at that time must have ensured that it was right. The nurse should clarify data with the client by asking additional questions to support the objective data.

A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?

Details are often missing Rationale: CBE may pose legal problems, because details are often missing. CBE does not omit subjective assessment, CBE is an ethical form of charting, and the question does not indicate that the assessment skills of the nurse are lacking in any form.

Why is accurate and effective documentation most important?

Documentation constitutes a legal record. Rationale: The client record serves as a legal document recording the client's health status and any care he or she receives. The client record can be used in civil or criminal courts to provide evidence of wrongdoing.

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?

Narrative notes Rationale: One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

In order to help out the staff in completing admission tasks during a busy shift, the charge nurse is completing the admission database for a staff nurse. What is the charge nurse's best action?

Place the completed assessment in the medical record. Rationale: The database should be placed in the medical record for access by all healthcare professionals who may need to review the client's information. The nurse should allow some time for documentation of findings and analysis of data. In addition to positive findings, it is essential to document absence of findings because, in the legal world, "if it's not documented, it's not done." The database should be completed in its entirety on admission. The client may be young, but an initial fall assessment score should be assessed.

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?

Progress notes

To make a legal entry into the medical record, the nurse must document what?

Time of the assessment Rationale: The nurse must record normal assessment data, abnormal assessment data, and the time of the assessment. The nurse does not have to document laboratory tests ordered, the attending physician, or the nature of the assessment.

After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?

To communicate effectively with other health care team members

The nurse is preparing to document assessment findings in a client's record. The nurse should

avoid slang terms or labels unless they are direct quotes.

A nurse is caring for a client who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called:

charting by exception Rationale: Charting by exception uses predetermined standards and norms to record only significant assessment data, and only abnormal findings require additional documentation. Narrative charting is done using unstructured paragraphs to record assessments and other activities. Pie charting includes stating the problem, interventions, and evaluation. Batch charting is waiting until the end of shift or after all clients have been assessed to chart.

The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form

prevents missed questions during data collection.