Chapter 16: Documenting, Reporting, Conferring, and Using Informatics

A client is scheduled for a CABG procedure. What information should the nurse provide to the client?

"A coronary artery bypass graft will benefit your heart."

To improve communication within the health care system, tools were created to standardize the process and assist with clarity and conciseness. SBAR is one such tool. In this tool, what does R stand for?

Recommendations SBAR stands for Situation, Background, Assessment, and Recommendations.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data.

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

urine output 100 ml

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records."

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which people would be entitled to access of the client's records?

those directly involved in the client's care

A nursing student has established a strong therapeutic rapport with a patient who was admitted to the hospital with a perforated appendix. The patient is similar in age to the student and is interested in a career in nursing. Before being discharged, the patient asks if she can add the student as a contact on a social networking site in order to ask her more questions about nursing. How should the student respond to the patient's request?

Explain that nurses are not permitted to have social contact with patients but offer to answer questions before the patient is discharged.

The nurse is using the SOAP format of charting during a home visit to a new mother. Which of the following data should the nurse document under the "P" domain of this format?

"Client referred to the health unit's drop-in breastfeeding clinic."

Which characteristics identify documentation as effective? Select all that apply.

-Readable - Thoughtful -Timely, contemporaneous, and sequential -Clear, concise, and complete

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

omitting client's response to nursing interventions

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

A flow sheet

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. What response by the nurse is most appropriate?

Explain the reason why information cannot be disclosed.

A client has been diagnosed with PVD. What area of the body should the nurse focus the assessment?

The lower extremities Peripheral vascular disease mostly affects the lower extremities. While the lung sounds, heart rate and rhythm, and abdominal assessment will be important, the focused assessment should be on the lower extremities.

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 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 finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting."

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. Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among healthcare providers is an advantage of problem-oriented recording and is therefore correct. Giving the clients the right to withhold the release of their information to anyone is beneficial disclosure, and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving the clients' problem among caregivers and having numerous locations for information where each member of the multidisciplinary team makes entries about their own specific activities in relation to the client's care are examples of source-oriented recording.

Which strategy could be implemented by the nurse in ensuring the protection of electronic data at healthcare agencies?

The nurse locks out client information, except to those who have been authorized through appropriate security measures.

A patient who is well-known to the community nurse has been admitted to the hospital for acute care. Which of the following principles should inform the nurse's response to the hospital's request for an e-mail summary of the patient's history?

The nurse should obtain the patient's written consent for e-mailing information to the hospital.

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 referral.

What situation would permit the nurse to disclose information without the client's approval?

the nurse suspecting that a client is being abused or neglected

A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology?

Telemedicine and mobile technology

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

Which scenario is an example of using patient records for quality assurance purposes?

Records are randomly selected to determine whether certain standards of care were met and documented. Quality assurance is when records are randomly selected to determine whether certain standards of care were met and documented. Care planning is when the nurse considers all data on the patient record when developing, goals, outcome criteria, interventions, and evaluation criteria for and with patients. Research is performed when data are gathered from groups of records to determine significant similarities in disease presentation, to identify contributing factors, or to determine the effectiveness of therapies. The medical record can be used for educational purposes such as when it is used, by a student, to learn how a disease might present itself in certain patients.

The nurse hears an unlicensed assitive personel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

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

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?

Incident report

A nursing student has searched the literature from information on the care of venous ulcers. After finding an article that specifically addresses this clinical topic, the student should prioritize what question?

"How credible is this information?"

Which nurse to provider interaction correctly utilizes the SBAR format for improved communication?

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." SBAR refers to: S (Situation): What is the situation you are calling about; B (Background): Pertinent background information related to the situation; A (Assessment): What is your assessment of the situation; R (Recommendation): Explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.

A nurse is requesting to receive the change of shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving report at the bedside. Which response by the nurse receiving report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care."

A nurse helps a client who has cystic fibrosis prepare a standalone personal health record. Which statement by the nurse best explains this type of information?

"You can fill in information from your own records and store it on your computer or the Internet."

The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? Select all that apply.

-Documentation must be kept of personnel who have accessed a client's record. -Light boxes for examining X-rays with the client's name must be in private areas. -Conversations about clients must take place in private places where they cannot be overheard. Documentation must be kept of personnel who have accessed a client's record, light boxes for examining X-rays with the client's name must be in private areas, and conversations about clients must take place in private places where they cannot be overheard are useful strategies to limit casual access to the identity of clients and health informatics. Computer screens that are oriented toward the public view and visibly displaying clients' names on charts are incorrect, as these are breaches of patient confidentiality.

The nursing student is reading the plan of care established by the RN in the clinical facility. The students asks the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states:

Although not written, the nurse must know or question the rationale before performing an action.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member

What is the primary purpose of the client record?

Communication

An EHR system is being introduced into a large health-care organization and nurses are being careful to ensure that the system adheres to the Canadian Nurses Association (CNA) Code of Ethics. What action is most likely to achieve this goal?

Ensuring that privacy and confidentiality are thoroughly protected by the system Privacy and confidentiality are the major ethical issues involved in the use of EHRs. Informed consent is necessary but not before each and every intervention or documentation entry. It is not always necessary or practical to validate documentation with the patient, and it is not normally necessary to educate patients and families on the specific operation of the EHR system.

Which statement is not true regarding a medication administration record (MAR)?

If the client refuses the dose you don't have to document this on the MAR.

Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing?

Nutritional consult

Which principle should guide the nurse's documentation of entries on the client's health care record?

Precise measurements should be used rather than approximations.

The nursing is caring for a client who requests to see a copy of his or her health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?

SOAP charting The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

A nursing student is beginning a clinical placement at a health-care facility that uses the Nursing Minimum Data Set (NMDS). The NMDS will assist the student in which of the following aspects of care?

Standardizing the collection and recording of data The NMDS was nursing's initial attempt to standardize the collection of essential nursing data and is comparable to traditional forms of documentation. The NMDS does not exist to elicit patient input, to diagnose health problems, or to compare the patient with other individuals.

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?

Subjective data should be included when documenting. Subjective data should be included when using the SOAP format for documentation. Objective data is what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care providers' judgment of the situation, and abnormal lab values would be included in objective data.

Which organization audits charts regularly?

The Joint Commission

A nursing student is admitting a new resident to a long-term care facility and will perform the admission assessment. What potential benefit of electronic documentation will affect the student's assessment?

The computer can prompt the student if he omits a necessary piece of data.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

Which characteristic of a nurse's charting will assist most in the avoidance of errors?

Timeliness

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?

identifying risks and ensuring future safety for clients