Chapter 17 Documenting and Reporting

How does the nurse maintain confidentiality and privacy when using an electronic health record (EHR)? Select all that apply.

By never sharing their username or password Rationale: Do not share a personal username or password with anyone. You are responsible for the data entered using your electronic identity. If someone else enters data or accesses records under your identity, you may be held responsible if the client initiates legal action. By regularly changing their password Rationale: Change your password at regular intervals. Do this even if your organization does not require it. By leaving the client's chart displayed inside client rooms only Rationale: Do not leave client data displayed on the screen where others can see it. By accessing records of past and current clients Rationale: Never access client health records you have no professional reason to view. This is a severe breach of client privacy rules. By permanently logging off the system when leaving an EHR Rationale: Close the screen, lock the computer, or permanently log off the system when moving away from an open EHR to help keep unauthorized viewers from having access to client information.

Which documentation of a client's pain would be the most appropriate?

Client complains of very bad pain in the head. Client is very obnoxious. Rationale: Documentation needs to be accurate, objective, and nonjudgmental. Document the client's pain score, or if possible, quote the client's own words. Client complains of pain rated 6 on a 0-10 scale. The assistive personnel said they are exaggerating. Rationale: Documentation needs to be objective. Avoid documenting what someone else thinks. Client complains of pain rated 6 on a 0-10 scale. Administered acetaminophen 1000 mg PO at 0900. Pain rated 3 at 1000. Rationale: When documenting a symptom, also document the intervention and the client's response. Administered acetaminophen 1000 mg PO at 0900 for a bad headache. The client seems better at 1000. Rationale: Avoid vague words like "bad" and "better" when documenting. When possible, give specific examples and descriptive details to allow caregivers to understand the client's individual needs.

Which are ways health providers use documentation to provide quality care? Select all that apply.

Communication tool Rationale: Members of the healthcare team use the medical record as a means of communicating client care and status. Continuity of care Rationale: Communication in the medical record promotes continuity of care. Shift report Rationale: The medical record can be referenced in the shift report but is not used as a tool for the report. Communication with family members Rationale: Due to confidentiality laws, the medical record cannot be shared with family members unless the client has given permission. Legal record Rationale: The medical record serves as legal evidence of care that has been provided.

Which elements of documentation can be delegated to unlicensed assistive personnel?

Documentation of initial assessment Rationale: Initial assessment is an important part of the nursing process and should be documented by a registered nurse. Documentation of the intensity and nature of the client's pain Rationale: Pain assessment is a nursing assessment and intervention. This cannot be delegated to unlicensed personnel. Documentation of vital signs and activities of daily living (ADLs) Rationale: ADLs and documentation of vital signs may be delegated to unlicensed assistive personnel. Documentation of medication administration Rationale: Medication administration is a nursing function and not in the scope of practice for unlicensed personnel. Test-Taking Tip In some facilities, different members of the healthcare team are responsible for documenting their portion of the care provided. Some documentation can be delegated to unlicensed personnel.

A nurse has concerns that an order written for a client is not appropriate. The provider is contacted, who insists the order is correct. The nurse still has reservations about carrying out the order. What is the appropriate course of action?

Inform the supervisor about the concerns regarding the order. Rationale: Any order that causes concern or does not seem right should be questioned. If the physician does not change the order, the nurse should take the concern up the chain of command, starting with the supervisor, then an administrator, and so on, until a resolution is reached. Carry out the order as it is part of the prescribed plan of care. Rationale: A nurse should never carry out an order about which there are concerns. If there is any hesitation, the nurse should question it. Refuse to carry out the order and document the reason for refusing it in the medical record. Rationale: The nurse cannot just refuse to carry out an order. There must first be a sincere attempt to clarify and resolve the order. Discuss it with the client and inform the client of their right to refuse treatment. Rationale: Any concern or disagreement about an order should not be discussed with the client, as this could erode the trust relationship in caregivers. The concern should be questioned and raised within the care team.

What should be considered when using abbreviations in nursing documentation?

It is acceptable to use common abbreviations in all documentation. Rationale: Not all common abbreviations are acceptable to use in a medical record. Some abbreviations have more than one meaning. Abbreviations should never be used in documentation. Rationale: There are instances in which approved abbreviations can be used as part of documentation. Each facility should have a list of approved abbreviations. Rationale: Each facility has a list of do-not-use abbreviations, as required by regulatory agencies such as The Joint Commission. Every medical record should have a reference to identify the meaning of any abbreviations. Rationale: It would be very time-consuming and difficult to add an addendum to every record to identify the meaning of abbreviations. This is not an acceptable practice.

What is the significance of using standardized reporting formats?

It is required by The Joint Commission. Rationale: Requirements by a regulatory agency should not be a driving force in providing safe care. It is the policy of most facilities. Rationale: Although a policy may dictate the use of a standardized reporting format, this is not the most significant reason for doing so. It is done to avoid serious errors due to miscommunication. Rationale: Errors can be prevented if a standardized reporting format is utilized. Because many errors occur as a result of miscommunication, a standardized format will minimize errors. It is done because physicians expect this practice among nurses. Rationale: The hand-off between caregivers should occur at all levels when care is passed from one provider to another. It should occur from physician to physician as well as from nurse to nurse. Test-Taking Tip Using a standardized reporting format minimizes the opportunity for errors in communication.

What are disadvantages of charting by exception? Select all that apply.

It requires nurses to be overly familiar with an organization's documentation standards. Rationale: Charting by exception requires nurses to be overly familiar with the organization's documentation standards and policies. It is difficult to capture the skilled judgment of nurses. Rationale: There is no opportunity for nurses to explain rationales for clinical decision- making and actions taken in response to an assessment. It is very cumbersome and time-consuming to use. Rationale: Charting by exception has the advantage of being very efficient, requiring minimal time and effort for documentation. It can lead to errors because nurses may conclude that care has been done when it has not. Rationale: Because care provided may not be thoroughly documented, a careful evaluation of care and a complete hand-off must be done when charting by exception is utilized. It results in repeat work when interventions or assessment findings are documented in multiple places. Rationale: Charting by exception involves minimal time and effort. There is virtually no opportunity for repeat work or duplicate documentation.

Which are examples of appropriate medication orders for an inpatient? Select all that apply.

Lasix by mouth twice daily Rationale: This order does not have a dosage associated with it. Aspirin 325 mg by mouth every morning Rationale: This order has all the elements of a complete medication order. Tylenol 500 mg prn Rationale: This order does not indicate what criteria to meet for prn administration. Rocephin 200 mg IV q6h Rationale: This order has all the elements of a complete medication order. Ibuprofen 200 mg q4h prn fever or mild pain Rationale: This order has dosage, frequency, and prn indication but is missing route of administration. Test-Taking Tip Medication administration records contain orders and information about all medications prescribed to the client.

Place the items in the correct order used when documenting the nursing process for a client who is experiencing pain.

Place the items in the correct order used when documenting the nursing process for a client who is experiencing pain. Assessment: Client crying, verbalizes pain rated 10 on a 0 to 10 scale.Correct Position: 1 Nursing diagnosis: Altered comfort related to postoperative pain.Correct Position: 2 Plan: Order for pain medications received.Correct Position: 3 Implementation: Pain medications administered.Correct Position: 4 Evaluation: After pain medications, client reports pain rated 4 on a 0 to 10 scale.Correct Position: 5 Rationale: Follow the order of the nursing process when documenting any intervention. Begin with assessment, then nursing diagnosis, plan, implementation, and evaluation. Doing so will ensure an accurate description of the nursing judgment that led to an intervention and the results of that intervention.

Which tool does the nurse use to provide a comprehensive hand-off report to the oncoming nurse?

SOAP Rationale: SOAP is a type of documentation method consisting of subjective, objective, assessment, and plan. This is not used for hand-off communication. SBAR Rationale: Situation, background, assessment, and recommendation (SBAR) is an effective communication tool that can be customized for hand-off communication. CPOE Rationale: CPOE, computerized physician order entry, is a method of entering orders in which physicians order directly without utilizing administrative assistance. This is not a method of hand-off communication. MAR Rationale: A medication administration record (MAR) is a document in which all the information and administration guidelines for medications is kept. This is not a hand-off communication method. Test-Taking Tip Oral reporting is provided to maintain continuity of care and ensure complete transfer of information during hand-off. The report should be restricted to client-focused information and can be done in a variety of formats, with SBAR being recognized as the most effective.

Which type of organization of health records involves members of each discipline recording their findings in a separate section of the chart?

Source-oriented Rationale: In source-oriented record systems, members of each discipline record their findings in separate sections of the chart. Problem-oriented Rationale: Problem-oriented record systems are organized around the client's problems. Charting by exception Rationale: Problem-oriented charts involve documentation only where problem areas or exceptions to the norm exist. Improvement-oriented Rationale: Improvement orientation refers to process improvement that is driven by the medical records and review and audits of records. Test-Taking Tip A health records system is the overall process of creating, storing, and retrieving records in an organization. There are several different organization systems that can be utilized, and the one that best meets the needs of the clients and the organization is used.

client is admitted with pneumonia. How should the nurse document the initial assessment?

The client appears short of breath, with wheezing in all lung fields. Rationale: Documentation of a nursing assessment includes signs and symptoms and an indication of any actual or perceived problems. The client is admitted with pneumonia and the nurse will watch for respiratory symptoms. Rationale: The medical diagnosis is not part of the documentation of a nursing assessment. Respiratory treatments are given as ordered every 4 hours. Rationale: The plan of treatment is not part of the documentation of a nursing assessment. The client reports improved breathing after breathing treatments given. Rationale: This is documentation of a client's response to a nursing intervention.

Which entries would the nurse include in the SOAP note? Select all that apply.

The client complains of pain at the incision site. Rationale: Subjective data (complaint of pain) are part of the SOAP note. Redness and edema are noted at the incision site. Rationale: Objective data (redness and edema) are part of the SOAP note. The client was discharged home in stable condition. Rationale: Documentation of client discharge is not part of the SOAP note. The physician was notified about signs of infection at the incision site. Rationale: Notification of the physician (plan) is part of the SOAP note. The physician performed rounds, visiting the client in the morning. Rationale: Recording that the physician performed rounds and saw the client is not part of SOAP documentation. Test-Taking Tip SOAP charting—subjective, objective, assessment, and plan—is commonly used to outline findings and the status of the client on a particular shift.

The nurse receives a written order with handwriting that is unclear. What action should the nurse take?

Try to use clinical judgment to decide what the order should state. Rationale: An order is a prescribed plan of care from the physician. The nurse should not guess the meaning of an unclear order. Contact the provider for clarification. Rationale: The provider should be contacted and the order clarified before it is administered. Refuse to perform the order. Rationale: The order should not be refused without an attempt to escalate the concern and obtain clarification. Document that the order was unclear. Rationale: An order that is unclear should be clarified, and there should not be any implication regarding the physician in the documentation. The healthcare team should work together.