Chapter 18: Document and Report

An informatics nurse is training a group of students on the advantages of using an EHR. What could be some supporting reasons? Select all that apply. 1. Can be used by several team members simultaneously 2. Less repetition of data 3. Faster 4. More accurate reporting 5. Less "down time"

1. Can be used by several team members simultaneously 2. Less repetition of data 3. Faster 4. More accurate reporting

Which information should always be included in a report in which a client is transferred from one unit to another? Select all that apply. 1. Client's name, age, and diagnosis 2. Last set of vital signs 3. History of appendectomy 5 years prior 4. Allergy to penicillin 5. Tubes, lines, or IV therapy

1. Client's name, age, and diagnosis should include relevant current information 2. Last set of vital signs latest assessment findings 5. Tubes, lines, or IV therapy any current [WRONG] 3. History of appendectomy 5 years prior a remote history of appendectomy is not relevant to the client's current health-care needs 4. Allergy to penicillin would be part of the electronic health record, and it will be noted in the MAR

Which are ways health providers use documentation to provide quality care? Select all that apply. 1. Communication tool 2. Continuity of care 3. Provide shift report 4. Communicate with family members 5. Legal record

1. Communication tool use medical record as a means of communicating client and status 2. Continuity of care communication in the medical record promotes continuity of care 5. Legal record the medical record serves as legal evidence of care that has been provided [WRONG] 3. Provide shift report the medical record can be referenced in the shift report but not used as a tool for the report 4. Communicate with family members Due to confidentiality laws, the medical record cannot be shared with family members unless the client has given permission

Which are document expectations? 1. Detailed 2. Complete 3. Bias free 4. Readable 5. Accurate 6. Extensive 7. Defensible

1. Detailed 2. Complete 3. Bias free 5. Accurate 7. Defensible The ABCs of documentation say that documents should be Accurate, Bias free, Complete, Detailed, Easy to read, Factual, Grammatical, Harmless (legally)

Which are outcomes of effective nursing documentation? Select all that apply. 1. Efficient time management 2. Cost-conscious nursing care 3. Effective nurse-client relationships 4. Continuity of client care 5. Safe nursing practice

1. Efficient time management 4. Continuity of client care 5. Safe nursing practice

Which are commonly used documentation forms? 1. Flow sheets and graphic records 2. Family relationship form 3. Hand-off report 4. Admission data forms 5. Student tracking form 6. History and physical 7. Discharge summary 8. Occurrence report

1. Flow sheets and graphic records 4. Admission data forms 6. History and physical 7. Discharge summary 8. Occurrence report A variety of forms are used in the patient record, including admission data forms, discharge summary, flow sheets, graphic records, checklists, medication administration records, intake and output records, care plans, and Kardex. Additional documentation forms that are not kept with the patient record include occurrence reports, which record an incident of risk or potential risk. These are typically kept by the administration of the agency.

What is the purpose of documentation? 1. Improving the facility's care quality 2. Facilitating communication among team members 3. Allowing nurses to summarize physician findings 4. Providing consistent care from shift to shift 5. Sharing data with insurance companies 6. Tracking the nurses on each shift 7. Creating legal report of care delivery

1. Improving the facility's care quality 2. Facilitating communication among team members 4. Providing consistent care from shift to shift 7. Creating legal report of care delivery Charting provides a record for communication, continuity of care, quality improvement, planning and evaluation of client outcomes, and legal protection, among other things. It needs to be complete, accurate, and timely. Insurance companies may use documentation to determine payment or deny reimbursement, but the intention of documentation is not for insurance companies. The record must be focused on the patient, not on what the nurse has done. Nurses may only document their own assessment and care.

A nurse has concerns that an order written on a client is not appropriate. She contacts the physician, who insists the order is correct. The nurse still has reservations about carrying out the order. What is the appropriate course of action? 1. Inform her supervisor about her concerns regarding the order. 2. Carry out the order, as it is part of the prescribed plan of care. 3. Refuse to carry out the order and document the reason for refusing it in the medical record. 4. Discuss it with the client and inform the client of his or her right to refuse treatment.

1. Inform her supervisor about her concerns regarding the order. Any order that concerns 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 her supervisor, then an administrator and so on, until a resolution is reached [WRONG] 2. Carry out the order, as it is part of the prescribed plan of care. a nurse should never carry out an order about which she has concerns. If there is any hesitation, the nurse should question 3. Refuse to carry out the order and document the reason for refusing it in the medical record. the nurse cannot just refuse to carry out an order. There must first be a sincere attempt to clarify and resolve the order 4. Discuss it with the client and inform the client of his or her right to refuse treatment. 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 with care team

The nurse is reviewing documentation forms in the facility where she was recently hired. What are some commonly used forms? Select all that apply. Checklists 1. Kardex 2. Care plans 3. Medication administration records 4. Intake and output records 5. checklists

1. Kardex 2. Care plans 3. Medication administration records 4. Intake and output records 5. checklists

What are some advantages of electronic records? 1. More secure 2. Can be used by several people at once 3. More accurate 4. Less "down time" 5. Can transfer information to multiple departments 6. Less repetition 7. Neater and easier to read 8. Saves time for nurses

1. More secure 2. Can be used by several people at once 3. More accurate 5. Can transfer information to multiple departments 6. Less repetition 7. Neater and easier to read 8. Saves time for nurses The use of the electronic health record has been shown to significantly reduce human error. Many systems can auto-populate with compatible electronic equipment (IV pumps, vital sign equipment, etc.) and provide "safety warnings" if the wrong medication is about to be given or there is an allergy. These systems are becoming more advanced all the time.

What are disadvantages of charting by exception? Select all that apply. 1. Pertinent information could be omitted because it is not considered significant. 2. It is difficult to capture the skilled judgment of nurses. 3. It is very cumbersome and time-consuming to use. 4. It can lead to errors because nurses may conclude that care has been done when it has not. 5. It results in repeat work when interventions or assessment findings are documented in multiple places.

1. Pertinent information could be omitted because it is not considered significant. disagreements over what is considered significant information could lead to gaps in documentation 2. It is difficult to capture the skilled judgment of nurses. there is no opportunity for nurses to explain rationales for clinical decision making and actions taken in response to an assessment 4. It can lead to errors because nurses may conclude that care has been done when it has not. since 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 [WRONG] 3. It is very cumbersome and time-consuming to use. charting by exception has the advantage of being very efficient, requiring minimal time and effort for documentation 5. It results in repeat work when interventions or assessment findings are documented in multiple places. charting by exception involves minimal time and effort. There is virtually no opportunity for repeat work or duplicate documentation

What are some common charting formats? 1. Problem—Intervention—Evaluation 2. Summarize, Organize, Assessment, Plan, Implement, Evaluate 3. Narrative 4. SOAPIE 5. Exception 6. Medication Administration Record 7. Emergency 8. Focus Charting®

1. Problem—Intervention—Evaluation 3. Narrative 4. SOAPIE 5. Exception 8. Focus Charting® Problem-Intervention-Evaluation (PIE) charting focuses on patient problems by identifying the problem, telling what the nurse did about it, and evaluating the client's response to the intervention. Narrative documentation tells a chronological story in words. For example, some nurses write a sequence of events and the subsequent actions taken as they unfold. DAR is the acronym for data, action, and response, a column used with Focus Charting®; the other two columns in this system contain date and time and the focus, or problem, addressed in the note. Charting by exception, another format, refers to a system in which only the exceptions to standards are documented. For example, if a client did not meet a specific standard, a documentation note is made. The SOAPIE note is another format used to write nursing and other progress notes. SOAPIE stands for Subjective data, Objective data, Assessment, Plan, Interventions, and Evaluation.

Which type of organization of health records involves members of each discipline recording their findings in a separate section of the chart? 1. Source-oriented 2. Problem-oriented 3. Charting by exception 4. Improvement-oriented

1. Source-oriented [WRONG] 2. Problem-oriented organized around the client's problems 3. Charting by exception Problem-oriented involve documentation only where problem areas or exception to the norm exist 4. Improvement-oriented refers to process improvement that is driven by the medical records and review and audits of records

Which represents correct documentation in the medical record of an initial nursing assessment of a client admitted with pneumonia? 1. The client appears short of breath, with wheezing in all lung fields. 2. The client is admitted with pneumonia and the nurse will watch for respiratory symptoms. 3. Respiratory treatments are given as ordered every 4 hours. 4. The client reports improved breathing after breathing treatments given.

1. The client appears short of breath, with wheezing in all lung fields. it includes signs and symptoms and an indication of an actual or perceived problems [WRONG] 2. The client is admitted with pneumonia and the nurse will watch for respiratory symptoms. the medical diagnosis is not part of documenting nursing assessment 3. Respiratory treatments are given as ordered every 4 hours. it is not part of documentation 4. The client reports improved breathing after breathing treatments given. this is a documentation of a client's response to a nursing intervention

Which chart entry would be part of SOAP documentation? Select all that apply. 1. The client complains of pain at the incision site. 2. Redness and edema is noted at the incision site. 3. The client was discharged home in stable condition. 4. The physician was notified about signs of infection at the incision site. 5. The physician performed rounds, visiting the client in the morning.

1. The client complains of pain at the incision site. subjective data (complaint of pain) is part of the SOAP note 2. Redness and edema is noted at the incision site. objective data (redness and edema) is part of the SOAP note 4. The physician was notified about signs of infection at the incision site. notification of the physician (plan) is part of the SOAP note

Which are common forms of oral communication? 1. Transfer report 2. SBAR 3. Bedside report 4. Face-to-face report 5. Kardex 6. Verbal orders 7. Handoff report 8. Telephone orders

1. Transfer report 2. SBAR 3. Bedside report 4. Face-to-face report 6. Verbal orders 7. Handoff report 8. Telephone orders Oral communication among healthcare team members is important. As with written or electronic communication, it has a high incidence of human error. It is critical for nurses to communicate clearly and accurately to prevent costly mistakes.

Which abbreviations are on The Joint Commission's "do not use" list? 1. U or u 2. MS for magnesium sulfate 3. Q.D. for daily 4. Lack of leading zero (.X mg) 5. q for every 6. oz for ounce 7. IU 8. Q.O.D.

1. U or u 2. MS for magnesium sulfate 3. Q.D. for daily 4. Lack of leading zero (.X mg) 7. IU 8. Q.O.D. The use of abbreviations in healthcare documentation has been a practice for decades. In the past 20 years, we've become much more aware of patient safety and human errors in healthcare delivery. With this knowledge, abbreviations have been identified as a high-risk area for human injury caused by misunderstanding of their meaning.

Which are common documentation guidelines for nurses? 1. Use chronological order. 2. Use block charting. 3. Document after each observation. 4. Never use late entries. 5. Document throughout the shift. 6. Document ahead when possible.

1. Use chronological order. 3. Document after each observation. 5. Document throughout the shift. Documentation should be timely, accurate, chronological, and consistently performed. When a nurse is caring for multiple clients, details may be easily forgotten or confused, so documenting after each observation and throughout the shift is important. A nurse cannot document ahead because that would record what he or she thinks will happen and not the facts of what actually happened. Block charting is the use of time ranges and should be avoided. Specific details are most accurate. Late entries are acceptable when a nurse has forgotten to document something, but should be noted as a "late entry."

Which are examples of appropriate medication orders? Select all that apply. 1. Lasix by mouth twice daily 2. Aspirin 325 mg by mouth every morning 3. Tylenol 500 mg prn 4. Rocephin 200 mg IV q6h 5. Ibuprofen 200 mg q4h prn fever or mild pain

2. Aspirin 325 mg by mouth every morning This order has all the element of a complete medication order 4. Rocephin 200 mg IV q6h This order has all the elements of a complete medication order 5. Ibuprofen 200 mg q4h prn fever or mild pain This order has dosage, frequency, and prn indication [WRONG] 1. Lasix by mouth twice daily This order does not have a dosage associated 3. Tylenol 500 mg prn This does not indicate what criteria to meet for prn administration

If a written order is confusing or unclear, what action should the nurse take? 1. Try to use clinical judgment to decide what the order should state. 2. Contact the provider for clarification. 3. Refuse to perform the order. 4. Document that the order was unclear.

2. Contact the provider for clarification. the provider should be contacted and the order clarified before it is administered [WRONG] 1. Try to use clinical judgment to decide what the order should state. An order is prescribed plan of care from the physician. The nurse should not guess the meaning of an unclear order 3. Refuse to perform the order. The order should not be refused without an attempt to escalate the concern and obtain clarification 4. Document that the order was unclear. An order that is unclear should be clarified and there should not be any implication regarding the physician in the documentation. The health care team should work together

The nurse documents: D: The client is wheezing and experiencing some shortness of breath with exertion A: Delivered 2 puffs of inhaler. R: Wheezing lessened after 5 minutes. Which type of documentation is this an example of? 1. Narrative 2. Focus Charting® 3. PIE 4. Charting by exception

2. Focus Charting®

Which is a method of providing a complete communication during a hand-off report? 1. SOAP 2. SBAR 3. CPOE 4. MAR

2. SBAR situation, background, assessment, and recommendation is an effective communication tool that can be customized for hand-off communication [WRONG] 1. SOAP type of documentation method consisting of subjective, objective, assessment, and plan. This is not used for hand-off communication 3. 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 4. MAR A medication administration record is a document in which all the information and administration guidelines for medication is kept. This is not a hand-off communication method

Nursing documentation should be which of the following? Select all that apply. 1. Dispensable 2. Specific 3. Opinionated 4. Nonjudgmental 5. Accurate

2. Specific 4. Nonjudgmental 5. Accurate

Which elements of documentation can be delegated to unlicensed assistive personnel? 1. Documentation of initial assessment 2. Documentation of the intensity and nature of the client's pain 3. Documentation of vital signs and activities of daily living (ADLs) 4. Documentation of medication administration

3. Documentation of vital signs and activities of daily living (ADLs) [WRONG] 1. Documentation of initial assessment important part of the nursing process and should be documented by a RN 2. Documentation of the intensity and nature of the client's pain pain assessment is a nurse assessment and intervention. This cannot be delegated 4. Documentation of medication administration It is a nursing function and not in the scope of practice for unlicensed personnel

What should be considered when using abbreviations in nursing documentation? 1. It is acceptable to use common abbreviations in all documentation. 2. Abbreviations should never be used in documentation. 3. Each facility should have a list of approved abbreviations, and those that should not be used. 4. Every medical record should have a reference as an addendum to identify the meaning of any abbreviations.

3. Each facility should have a list of approved abbreviations, and those that should not be used. Each facility has a list of do-not-use abbreviations, as required by regulatory agencies such as The Joint Commission [WRONG] 1. It is acceptable to use common abbreviations in all documentation. Not all common abbreviations are acceptable to use in a medical record. Some abbreviations have some more than one meaning 2. Abbreviations should never be used in documentation. there are instances in which approved abbreviations can be used as a part of documentation 4. Every medical record should have a reference as an addendum to identify the meaning of any abbreviations. 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? 1. It is required by The Joint Commission 2. It is the policy of most facilities 3. Many serious errors occur as a result of miscommunication between caregivers 4. Physicians expect this practice among nurses

3. Many serious errors occur as a result of miscommunication between caregivers. Errors can be prevented if a standardized reporting format is utilized. Some many errors occur as a result of miscommunication, a standardized format will minimize errors [WRONG] 1. It is required by The Joint Commission Requirements by a regulatory agency should not be a driving force in providing safe care 2. It is the policy of most facilities Although a policy may dictate the use of a standardized reporting format, this is not the most significant reason for doing so 4. Physicians expect this practice among nurses 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

If an error is made in nursing documentation, what should the nurse do? 1. The error must remain in the record because health records cannot be altered. 2. The error must be deleted. 3. The entry is noted as being an error, and an addendum with correct information is added. 4. The medical record must be discarded and a new one started.

3. The entry is noted as being an error, and an addendum with correct information is added. The error must be noted, either a line drawn through in a paper record or marked as an error in an EMR, and an addendum is added with correction [WRONG] 1. The error must remain in the record because health records cannot be altered. an error cannot remain as part of the client's medical record. It must be corrected 2. The error must be deleted. An error into the medical record cannot be deleted, but an error must be marked as such and a correction added 4. The medical record must be discarded and a new one started. The process of recreating a medical record is cumbersome, and it could be illegal. A medical record cannot be discarded due to an error

Which is the correct order when documenting the nursing process for a client who is experiencing pain? 1. Plan: Order for pain medications received 2. Implementation: Pain medications administered 3. Evaluation: After pain medications, client reports pain rated 4 on a 0-10 scale 4. Nursing diagnosis: Altered comfort related to postoperative pain 5. Assessment: Client crying, verbalizes pain rated 10 on a 0-10 scale

5. Assessment: Client crying, verbalizes pain rated 10 on a 0-10 scale 4. Nursing diagnosis: Altered comfort related to postoperative pain 1. Plan: Order for pain medications received 2. Implementation: Pain medications administered 3. Evaluation: After pain medications, client reports pain rated 4 on a 0-10 scale