Chapter 10 documentation
The nurse understands the need for accurate documentation due to which fact? a. Accurate documentation is needed for proper reimbursement. b. Accurate documentation must be electronically generated. c. Accurate documentation does not include e-mails or faxes. d. Accurate documentation is only accepted in court if written by hand.
ANS: A Accurate documentation is necessary for hospitals to be reimbursed according to diagnostic-related groups (DRGs). DRGs are a system used to classify hospital admissions. Health care documentation is any written or electronically generated information about a patient that describes the patient, the patient's health, and the care and services provided, including the dates of care. These records may be paper or electronic documents, such as electronic medical records, faxes, e-mails, audiotapes, videotapes, and images. All such records are considered legal documentation and may be used in court.
The nurse understands which statement about the use of electronic health records is true? a. They improve patient health status. b. They require a keyboard to enter data. c. They have not reduced medication errors. d. They require increased storage space.
ANS: A Adoption of an EHR system produces major cost savings through gains in productivity and error reduction, which ultimately improves patient health status. The most common benefits of electronic records are increased delivery of guideline-based care, better monitoring, reduced medication errors, and decreased use of care. Use of EHRs can reduce storage space, allow simultaneous access by multiple users, facilitate easy duplication for sharing or backup, and increase portability in environments using wireless systems and hand-held devices. Although data are often entered by keyboard, they can also be entered by means of dictated voice recordings, light pens, or handwriting and pattern recognition systems.
The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. What is the best central location for the nurse to obtain this information? a. Admission summary b. Discharge summary c. Flow sheet d. Kardex
ANS: A An admission summary includes the patient's history, a medication reconciliation, and an initial assessment that addresses the patient's problems, including identification of needs pertinent to discharge planning and formulation of a plan of care based on those needs. The discharge summary addresses the patient's hospital course and plans for follow-up, and it documents the patient's status at discharge. It includes information on medication and treatment, discharge placement, patient education, follow-up appointments, and referrals. Flow sheets and checklists may be used to document routine care and observations that are recorded on a regular basis, such as vital signs, medications, and intake and output measurements. Although computerization of records may mean that the Kardex system is no longer active, the term kardex continues to be used generically for certain patient information held at the nurses' station.
When the patient has had a fall while trying to climb out of bed, the nurse must carry out which task? a. Complete an incident report as a risk management document. b. Complete an incident report and add it to the medical record. c. Document that an incident report was completed in the medical record. d. Say nothing about the incident in the medical record.
ANS: A Incident reports are objective, nonjudgmental, factual reports of the occurrence and its consequences. The incident report is not part of a medical record but is considered a risk management or quality-improvement document. The fact that an incident report was completed is not recorded in the patient's medical record; however, the details of a patient incident are documented.
The nurse recognizes which statement to be accurate regarding what should be documented? a. Document facts and subjective data from the patient. b. Document how he/she feels about the care being provided. c. Document in a "block" fashion once per shift. d. Double document as often as possible in order to not miss anything.
ANS: A Nursing documentation is an important part of effective communication among nurses and with other health care providers. Documentation should be factual and nonjudgmental, with proper spelling and grammar. Subjective data from the patient should be included. Events should be reported in the order they happened, and documentation should occur as soon as possible after assessment, interventions, condition changes, or evaluation. Each entry includes the date, time, and signature with credentials of the person documenting. Double documentation of data should be avoided because legal issues can arise as a result of conflicting data.
The nurse recognizes that nursing documentation is guided by what process? a. The nursing process b. NANDA-I, nursing diagnoses c. Nursing interventions classification d. Nursing Outcomes Classification
ANS: A Nursing documentation is guided by the five steps of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. Standardized nursing terminologies such as the North American Nursing Diagnosis Association-International (NANDA-I) Nursing Diagnoses, nursing interventions classification (NIC), and Nursing Outcomes Classification (NOC) may be used in the documentation process.
The nurse knows that paper records are being replaced by other forms of record keeping for what reason? a. Paper is fragile and susceptible to damage. b. Paper records are always available to multiple people at a time. c. Paper records can be stored without difficulty and are easily retrievable. d. Paper records are permanent and last indefinitely.
ANS: A Paper records have several potential problems. Paper is fragile, susceptible to damage, and can degrade over time. It may be difficult to locate a particular chart because it is being used by someone else, it is in a different department, or it is misfiled. Storage and control of paper records can be a major problem.
The nurse knows that the Health Insurance Portability and Accountability Act (HIPAA) allows health information to be shared in which circumstances? (Select all that apply.) a. To provide treatment for the patient b. To determine billing and payment issues c. To enhance health care operations related to the patient d. In public areas such as the cafeteria or elevator e. Over the telephone with any family member
ANS: A, B, C The Health Insurance Portability and Accountability Act (HIPAA), originally passed in 1996, created standards for the protection of personal health information, whether conveyed orally or recorded in any form or medium. The act clearly mandates that protected health information may be used only for treatment, payment, or health care operations. HIPAA privacy standards should be applied during phone, fax, e-mail, or Internet transmission of protected patient information.
The nurse understands the use of standardized language in care planning is beneficial for what reasons? (Select all that apply.) a. Standardized language provides consistency. b. Standardized language improves communication among nurses. c. Standardized language increases the visibility of nursing interventions. d. Standardized language enhances data collection. e. Standardized language supports adherence to care standards.
ANS: A, B, C, D Standardized nursing terminologies such as the North American Nursing Diagnosis Association-International (NANDA-I) Nursing diagnoses, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) may be used in the documentation process. Use of standardized language provides consistency, improves communication among nurses and with other health care providers, increases the visibility of nursing interventions, improves patient care, enhances data collection to evaluate nursing care outcomes, and supports adherence to care standards.
The nurse identifies which components to be expected nursing documentation? (Select all that apply.) a. Nursing assessment b. The care plan c. Critique of the physician's care d. Interventions e. Patient responses to care
ANS: A, B, D, E Expected nursing documentation includes a nursing assessment, the care plan, interventions, the patient's outcomes or response to care, and assessment of the patient's ability to manage after discharge. Documentation should be factual and nonjudgmental.
When charting is done using the DAR charting format, the nurse documents which components? (Select all that apply.) a. The patient problems b. Subjective data c. Any actions initiated d. Objective data e. The patient's response to interventions
ANS: A, C, E A DAR note is used to chart the data (D) collected about the patient problems, the action (A) initiated, and the patient's response (R) to the actions. A SOAP note is used to chart the subjective data (S), objective data (O), assessment (A), and plan (P).
If a verbal or phone order is necessary in an emergency, the nurse knows what action needs to be completed? a. The order must be taken by an RN or LPN. b. The order must be repeated verbatim to confirm accuracy. c. The order is documented as a written order. d. The order does not need further verification by the provider.
ANS: B If a verbal or phone order is necessary in an emergency, the order must be taken by a registered nurse (RN) who repeats the order verbatim to confirm accuracy and then enters the order into the paper or electronic system, documenting it as a verbal or phone order and including the date, time, physician's name, and RN's signature. Most facility policies require the physician to co-sign a verbal or telephone order within a defined time period.
What fact is the nurse aware of when charting using electronic documentation? a. Errors can be corrected and totally removed from the record in the screen view. b. Log-on access to the electronic record identifies the person charting. c. Each entry requires the nurse to sign her/his name and credentials. d. Documenting significant changes in the electronic record ends the nurse's responsibility.
ANS: B Log-on access to the electronic record identifies the person charting or making a change. If an error is made in electronic documentation, it can be corrected on the screen view but the error and correction process remain in the permanent electronic record. Any correction in documentation that indicates a significant change in patient status should include notification of the primary care provider.
What fact does the nurse know applies to PIE, APIE, SOAP, and SOAPIE documentation? a. They are chronologic. b. They are examples of problem-oriented charting. c. They are narrative charting. d. They are forms of "charting by exception."
ANS: B The nurse's notes may be in a narrative format or in a problem-oriented structure such as the PIE, APIE, SOAP, SOAPIE, SOAPIER, DAR, or CBE format. Narrative charting is chronologic, charting by exception (CBE) is documentation that records only abnormal or significant data.
The nursing student is learning about SBAR reporting. What statements about the patient are matched with the correct part of the report? (Select all that apply.) a. Patient is an 84-year-old female with a history of hypertension: S b. Patient's blood pressure has dropped from 142/92 to 98/48 mmHg: S c. Patient is hemorrhaging with four saturated dressings in an hour: A d. The patient took an overdose of antidepressants three days ago: B e. By policy, the patient needs transferred to the ICU; please come write the orders: R
ANS: B, C, D, E SBAR stands for situation (what is happening the current time), background (circumstances leading up to this situation), assessment (what the nurse thinks the problem is), and recommendation (what needs to be done to correct the situation). A history of hypertension would be background (if it were related to the current issue).
2. The Joint Commission has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. The nurse identifies which abbreviations to be unacceptable? (Select all that apply.) a. prn b. QD c. qod d. 0.X mg e. X mg
ANS: B,C Nurses must be aware of the danger of using abbreviations that may be misunderstood and compromise patient safety. The Joint Commission (2018) has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. QD, Q.D., qd, q.d. (daily), QOD, Q.O.D., qod, and q.o.d. (every other day) can be mistaken for each other. Periods after Q can be mistaken for I, and the O mistaken for I. Write daily or every other day. Trailing zero (X.0 mg) or a lack of leading zero (.X mg) can be confusing. Write as X mg or 0.X mg.
Prior to preparing to administer medications to the patient, the nurse should compare the provider orders with what document? a. Flow sheet b. Kardex c. MAR d. Admission summary
ANS: C A medication administration record (MAR) is a list of ordered medications, along with dosages and times of administration, on which the nurse initials medications given or not given. A paper MAR usually includes a signature section in which the nurse is identified by linking the initials used with a full signature. The EHR includes an electronic medication administration record (eMAR). Flow sheets and checklists may be used to document routine care and observations that are recorded on a regular basis, such as vital signs, and intake and output measurements. Data collected on flow sheets may be converted to a graph, which pictorially reflects patient data. Originally, the Kardex was a nonpermanent filing system for nursing records, orders, and patient information that was held centrally on the unit. Although computerization of records may mean that the Kardex system is no longer active, the term kardex continues to be used generically for certain patient information held at the nurses' station. An admission summary includes the patient's history.
The nurse is caring for patients on a unit that uses electronic health records (EHRs). What action by the nurse protects personal health information? a. The nurse should allow only nurses that he/she knows and trusts to use his/her verification code. b. The nurse should not worry about mistakes since the information cannot be tracked. c. The nurse should never share any password with anyone. d. The nurse should be aware that the EHR is sophisticated and immune to failure.
ANS: C Access to an EHR is controlled through assignment of individual passwords and verification codes that identify people who have the right to enter the record. Passwords and verification codes should never be shared with anyone. Health care information systems have the ability to track who uses the system and which records are accessed. These organizational tools contribute to the protection of personal health information. Disadvantages of use of computers for documentation include computer and software failure and problems if there is a power outage.
The nurse identifies which statement to be accurate regarding the process of making a change-of-shift report (handoff)? a. Handoff is an uncommon occurrence of little importance. b. Handoff occurs only at change of shift and only to oncoming nurses. c. Handoff can lead to patient death if done incorrectly. d. Handoff does not allow for collaboration or problem solving.
ANS: C An ineffective handoff may lead to wrong treatments, wrong medications, or other life-threatening events, increasing the length of stay and causing patient injury or death. Improvement in the hand-off process can increase patient safety and promote positive patient outcomes. The hand-off process can be an opportunity for collaborative problem solving. During an average hospital stay of approximately 4 days, as many as 24 handoffs can occur for just one patient because shifts change every 8 to 12 hours and many individuals are responsible for care.
What action should the nurse take to correct an error in paper charting? a. Remove the sheet with the error and replace it with a new sheet with the correct entry. b. Scribble out the error and rewrite the entry correctly. c. Draw a single line through the error write "error" above or after the entry, along with the nurse's initials. d. Leave the entry as is and tell the charge nurse.
ANS: C Documentation mistakes must be acknowledged. If an error is made in paper documentation, a line is drawn through the error and the word error is placed above or after the entry, along with the nurse's initials and followed by the correct entry. Notes should never be altered or obliterated. Documentation mistakes must be acknowledged.
The nurse is admitting a patient who has had several previous admissions. To obtain a knowledge base about the patient's medical history, the nurse would access which document? a. Electronic medical record (EMR) b. The computerized provider order entry (CPOE) c. Electronic health record (EHR) d. Primary provider's office notes
ANS: C The EHR is a longitudinal record of health that includes the information from inpatient and outpatient episodes of health care from one or more care settings. The EMR is a record of one episode of care, such as an inpatient stay or an outpatient appointment. CPOE allows clinicians to enter orders in a computer that are sent directly to the appropriate department. It does not provide historical data. The primary provider's office notes may not include all the patient's information if the patient has other providers.
The nursing instructor teaching students about charting explains that this type of charting records only abnormal or significant data? a. PIE b. SOAP c. Narrative d. Charting by exception
ANS: D Charting by exception (CBE) is documentation that records only abnormal or significant data. A PIE note is used to document problem (P), intervention (I), and evaluation (E). A SOAP note is used to chart the subjective data (S), objective data (O), assessment (A), and plan (P). Narrative charting is chronologic, with a baseline recorded on a shift-by-shift basis. Data are recorded in the progress notes, often without an organizing framework. Narrative charting may stand alone, or it may be complemented by other tools.
When the nurse is charting in the paper medical record, what action does the nurse carry out? a. Print his/her name since signatures are often not readable. b. Omit nursing credentials since only the nurses chart c. Skip a line between entries so that it looks neat. d. Use black ink unless the facility allows a different color.
ANS: D Entries into paper medical records are traditionally made with black ink to enable copying or scanning, unless a facility requires or allows a different color. The date, time, and signature, with credentials of the person writing the entry, are included in the entry. No blank spaces are left between entries because they could allow someone to add a note out of sequence.
The nurse identifies which statement to be true regarding nursing documentation? a. Standards for documentation are established by a national commission. b. Medical records should be accessible to everyone. c. Documentation should not include the patient's diagnosis. d. High-quality nursing documentation reflects the nursing process.
ANS: D The ANA's model for high-quality nursing documentation reflects the nursing process and includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and retrievability. Standards for documentation are established by each health care organization's policies and procedures. They should be in agreement with The Joint Commission's standards and elements of performance, including having a medical record for each patient that is accessed only by authorized personnel. General principles of medical record documentation from the Centers for Medicare and Medicaid Services (2017) include the need for completeness and legibility; the reasons for each patient encounter, including assessments and diagnosis; and the plan of care, the patient's progress, and any changes in diagnosis and treatment.
What fact is the nurse aware of when charting using paper nursing notes? a. Use red ink so the nursing entries stand out. b. When mistakes are made in documentation, the nurse should white out the entry. c. Only one nurse should document on a sheet so that it can be removed in case of error. d. The medical record, in any format, is the most reliable source of information in a legal action.
ANS: D The medical record is seen as the most reliable source of information in any legal action related to care. When legal counsel is sought because of a negative outcome of care, the first action taken by an attorney is to acquire a copy of the medical record. Ink color is usually black, blue or other as designated by the facility. Notes should never be altered or obliterated. Documentation mistakes must be acknowledged. If an error is made in paper documentation, a line is drawn through the error and the word error is placed above or after the entry, along with the nurse's initials and followed by the correct entry.
The nurse identifies which true statement regarding the medical record? a. It serves as a major communication tool but is not a legal document. b. It cannot be used to assess quality of care issues. c. It is not used to determine reimbursement claims. d. It can be used as a tool for biomedical research and provide education.
ANS: D The medical record promotes continuity of care and ensures that patients receive appropriate health care services. The record can be used to assess quality-of-care measures, determine the medical necessity of health care services, support reimbursement claims, and protect health care providers, patients, and others in legal matters. It is a clinical data archive. The medical record serves as a tool for biomedical research and provider education, collection of statistical data for government and other agencies, maintenance of compliance with external regulatory bodies, and establishment of policies and regulations for standards of care. The record serves as the major communication tool between staff members and as a single data access point for everyone involved in the patient's care. It is a legal document that must meet guidelines for completeness, accuracy, timeliness, accessibility, and authenticity. The record can be used to assess quality-of-care measures, determine the medical necessity of health care services, support reimbursement claims, and protect health care providers, patients, and others in legal matters.