Chapter 19: Documentation PrepU

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? a. SBAR b. SOAP c. PIE d. MAR

a. SBAR The nurse should use SBAR (situation, background, assessment, recommendation) when communicating with the health care provider. SOAP and PIE are nursing notes in the medical record, and MAR is medication administration record.

In SBAR, what does R stand for? a. Reinforcing data b. Response c. Recommendations d. Report

c. Recommendations SBAR stands for situation, background, assessment, and recommendations. The other responses are incorrect.

Which is not a purpose of the client care record? a. To serve as a legal document b. To facilitate reimbursement c. To serve as a contract with the client d. To assist with care planning

c. To serve as a contract with the client Client care records are legal documents, communication tools, and assessment tools. They are used for care planning, quality assurance, reimbursement, research, and education. They in no manner reflect a contract between health care staff and the client. The only exception to this is at the point of admission when the client (or responsible party) signs an acknowledgement of expenses about to be incurred as health care insurance information is obtained.

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? a. The lower extremities b. Lung sounds c. Heart rate and rhythm d. The abdominal area

a. 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.

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate? a. Ask the client if information can be given to the parent. b. Provide the information to the parent. c. Explain the reasons for the hospitalization, but give no further information. d. Take the parent to the client's room and have the client give the requested information.

a. Ask the client if information can be given to the parent. No information should be provided by the nurse without permission from the client. Taking the parents to the client's room to get information from the client may violate the client's privacy.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? a. Inform the health care provider that a written order is needed. b. Write the order in the client's record. c. Call the pharmacy to have the order entered in the electronic record. d. Add the new order to the medication administration record.

a. Inform the health care provider that a written order is needed. Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.

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? a. Calling the client information desk to find out the room number of the family member b. Finding the emergency medical technicians who transported the family members and inquiring about the injuries c. Asking the emergency department nurse for information on the family member d. Accessing the electronic health record of the family member to find out extent of injury

a. Calling the client information desk to find out the room number of the family member Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? a. A never event b. A variance c. An audit d. A sentinel event

b. A variance This scenario reflects a variance in care. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client.

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation? a. SOAP b. narrative c. focus d. charting by exception

d. charting by exception Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. In the scenario, the BP is abnormal and is documented by exception. The other types of documentation are not being represented in this scenario.

What ensures continuity of care? a. reassessment b. critical thinking c. communication d. integration

c. communication Communication ensures continuity of care and provides essential data for revision of. or continuation of care. The acts of reassessment, critical thinking, and integration do not contribute directly to continuity of care.

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? a. data base b. problem list c. plan of care d. progress notes

d. progress notes In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.

What dual purpose does an audit serve? a. communication and evaluation b. knowledge and quality c. education and confidentiality d. quality assurance and reimbursement

d. quality assurance and reimbursement Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits have no role in communications, evaluation, knowledge, quality, education, or confidentiality.

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? a. Client's record and occurrence report b. Occurrence report and critical pathway c. Critical pathway and care plan d. Care plan and client's record

a. Client's record and occurrence report An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? a. "A coronary artery bypass graft will benefit your heart." b. "The CABG procedure will help identify nutritional needs." c. "A complete ablation of the biliary growth will decrease liver inflammation." d. "The CABG procedure will help increase intestinal motility and prevent constipation."

a. "A coronary artery bypass graft will benefit your heart." Coronary artery bypass graft is abbreviated CABG. It does not identify nutritional needs, decrease liver inflammation, or increase intestinal motility.

Which is the primary purpose of client records? a. Communication b. Reimbursement c. Legal protection d. Performance improvement

a. Communication Client records serve many purposes. The primary purpose of the client record is to help health care professionals from different disciplines (who interact with the client at different times) communicate with one another. Communication fosters continuity of care. The ANA states that the most important purpose of client records is "communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory and legislative, reimbursement, research, and quality activities."

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate? a. "Be sure to write down specific information for your clinical paperwork." b. "You can get an electronic printout of client lab data to take with you." c. "Clipboards with client data should not leave the unit." d. "Be sure to put the client's name and room number on all paperwork."

c. "Clipboards with client data should not leave the unit." HIPAA has created several changes that protect client confidentiality and affect the workplace. One such change is that the names of clients on charts can no longer be visible to the public, and clipboards must obscure identifiable names of clients and private information about them. Therefore, writing down clinical information, taking the data off the unit, and including client identifiers are inappropriate.

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? a. "I am calling because the client receiving blood has developed dyspnea and had crackles." b. "This client has a medical history of heart failure." c. "It seems like this client has fluid volume overload." d. "I think the client would benefit from intravenous furosemide."

d. "I think the client would benefit from intravenous furosemide." Situation, background, assessment, and recommendations (SBAR) provides a consistent method for hand-off communication that is clear, structured, and easy to use. The S (situation) and B (background) provide objective data, whereas the A (assessment) and R (recommendations) allow for presentation of subjective information. Calling to report dyspnea and crackles occurs as the nurse describes the situation. Providing the medical history occurs as the nurse offers important background information. Stating that the client has fluid volume overload is the assessment of the nurse. Stating that the nurse thinks the client would benefit from intravenous furosemide is the nurse's recommendation.

The nurse cared for a client admitted with uncontrolled hypertension. The client suffered a stroke shortly after the nurse's shift ended. Which information will determine if the nurse is liable? a. Failure to administer aspirin, as the client reported taking it at home b. Relaying report of nausea to the health care provider c. Administering acetaminophen for report of headache d. Omitting documentation of blood pressure at the end of the shift

d. Omitting documentation of blood pressure at the end of the shift Legal cases have been argued with the principle that "if it was not documented, it was not done." For this reason, it is important to document normal, as well as abnormal findings. Because nurses and other health care team members cannot remember specific assessments or interventions involving a client years after the fact, accurate and complete documentation at the time of care is essential. Failure to administer aspirin or the administration of acetaminophen would have been documented in the health record. Relaying a report of nausea would not have made the nurse liable for the client's status. Communication in the health record, as well as a report at shift change, is a vital part of nursing.

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? a. "Any information that can identify a person is considered a breach of client privacy." b. "You may continue to post about a client, as long as you do not use the client's name." c. "All aspects of clinical practice are confidential and should not be discussed." d. "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."

a. "Any information that can identify a person is considered a breach of client privacy." Any information that can identify a person is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the facility and unit is disclosed in the post. Discussion of clinical practice can be helpful for learning purposes or seeking advice on care. No care should be discussed, even privately, with friends and family without first obtaining the client's permission.

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? a. "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." "b. I am calling about the patient in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." c. "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." d. "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."

a. "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 it at the bedside. Which response by the nurse receiving the report is most appropriate? a. "It will allow for us to see the client and possibly increase client participation in care." b. "It will let me see everything that has been done and things that need to be done." c. "It makes our client feel like we care, especially if we start the day off with a clean room." d. "It will give me a better sense of what my workload will be today."

a. "It will allow for us to see the client and possibly increase client participation in care." Bedside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse? a. "Legal policy requires nursing practice to be permanently integrated into the client record." b. "It would be easier to do it that way. You could develop a tool to use." c. "The facility requires us to document client care this way because of the computer application used." d. "The electronic health record we use does not allow us to use different formats."

a. "Legal policy requires nursing practice to be permanently integrated into the client record." Legal policy requires nursing care documentation to be permanently integrated into the client record. Computer applications and electronic health record formats may have some differences, but they all use an integrated record. Suggesting that the nurse develop a new tool would be inappropriate, as separate nursing documentation would not be legal.

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate? a. "The benefit of CBE is less time needed on computer charting." b. "The benefit of CBE is that it demonstrates whether high-quality care is given." c. "CBE is the best way to protect against lawsuits." d. "CBE is a relatively new format of documentation in electronic health records."

a. "The benefit of CBE is less time needed on computer charting." One of the benefits of CBE is less time needed for documentation. CBE does not always support high-quality care and is not the best way to protect against lawsuits since not all data are documented. CBE is not a new format for documentation.

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? a. 1 Unit of glucose b. 1 bottle of glucose c. One U of glucose d. 1U of glucose

a. 1 Unit of glucose The nurse should write "1 Unit of glucose." The nurse cannot write "1 bottle" or "one U of glucose" because these are not the accepted standards. "1U" is an abbreviation that appears in the JCAHO "Do Not Use" list (see http://www.jcaho.com). It should be written as "1 Unit" instead of "1U" because "U" is sometimes misinterpreted as "zero" or "number 4" or "cc."

Which note includes all elements of a SOAP note? a. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness. b. Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. c. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. d. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess.

a. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness. A SOAP note consists of subjective information, objective information, an assessment, and a plan. The correct response includes each of these while the remaining three responses are each lacking a different one of the components.

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? a. Documentation b. Accreditation c. Psychomotor skills d. Clinical judgment

a. Documentation Documentation is the primary source of evidence used to measure performance outcomes, according to the CNA. Accreditation is the process whereby educational institutions are evaluated and, if approved, certified by a third party to validate their competency. Psychomotor skills are skills that require physical actions and muscular coordination to perform. Clinical judgment is an attribute of health care professionals that involves the use of critical thinking, intuition, and clinical experience when making a decision about a client's care to achieve the best outcome for the client.

The nurse mistakenly documented one client's assessment data on another client's health care record. What action should the nurse take? a. Draw a single line through the error, initial it, and write the correct entry. b. Use a dark-colored felt-tip pen to black out the error. c. Use correction fluid to cover the error and write the correct entry over it. d. Replace the record sheet and write the correct entry on the new sheet.

a. Draw a single line through the error, initial it, and write the correct entry. Draw a single line through an incorrect entry, write the words "mistaken entry" or "error in charting" above or beside the entry, and initial it. Then rewrite the entry correctly. The other options are not appropriate ways to correct an erroneous entry.

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legally defensible charting? a. Ensure that the client's name appears on all pages. b. Leave spaces between entries and signature. c. Use abbreviations wherever possible. d. Record all facts and subjective interpretations.

a. Ensure that the client's name appears on all pages. The nurse should ensure that the client's name appears on all pages to ensure legally defensible charting. The nurse should not leave spaces between entries and signature so that the document is legally acceptable. The nurse should use only abbreviations approved by the facility, and should not use abbreviations wherever possible. The nurse should record all the facts, but not any subjective interpretations, to ensure that the document is legal evidence.

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? a. Incident report b. Nurse's shift report c. Transfer report d. Telemedicine report

a. Incident report An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion

A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse best reflects the effectiveness of the pain medication? a. Rates pain 8/10, states nauseated for last 30 minutes. b. States pain is not relieved, talking with family on phone. c. Vital signs within normal limits, sleeping. d. Rates pain higher on pain scale, notified physician.

a. Rates pain 8/10, states nauseated for last 30 minutes. Using the pain scale gives a more objective and measurable evaluation of pain. Stating "Vital signs within normal limits, sleeping" does not evaluate effectiveness of the pain medication. The statement of pain not being relieved or pain higher on pain scale does not provide a definitive measurement of effectiveness in the documentation.

The nurse is providing documentation for the care rendered to clients. Which characteristics identify documentation as effective? Select all that apply. a. Readable b. Thoughtful c. Timely d. Clear, concise, and complete e. Accurate, relevant, and lengthy f. Retrievable on a temporary basis

a. Readable b. Thoughtful c. Timely d. Clear, concise, and complete Characteristics of effective documentation include accessible, accurate, relevant, consistent, auditable, clear, concise (not lengthy), complete, legible/readable, thoughtful, timely, contemporaneous, sequential, and retrievable on a permanent (not temporary) basis.

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? a. Remind the UAP about the client's right to privacy. b. Report the UAP to the nurse manager. c. Notify the client relations department about the breach of privacy. d. Document the UAP's conversation.

a. Remind the UAP about the client's right to privacy. The nurse should first remind the UAP about the client's right to privacy. All other actions are appropriate, but do not immediately protect the client's privacy.

Which actions should the nurse take before making an entry in a client's record? Select all that apply. a. Reviewing the agency's list of approved abbreviations b. Choosing the charting format that the nurse prefers c. Locating clients' files within an electronic health record system d. Identifying the form appropriate to be used for documenting e. Checking that clients' names are not identified within the chart forms

a. Reviewing the agency's list of approved abbreviations c. Locating clients' files within an electronic health record system d. Identifying the form appropriate to be used for documenting The nurse should review the agency's list of approved abbreviations, as each agency may use a different set of approved abbreviations and has approved its use for legally defensible reasons. The nurse should locate clients' files within an electronic health record system rather than creating a new record, to avoid duplication and missing important information in the client's record that was added previously. The nurse should identify the form appropriate to use for documenting, because some aspects of clients' care are recorded on specific forms. The nurse should use the charting format required by the facility, not choose one that the nurse prefers. The client's name should be identified on chart forms, so that if the forms become separated from the chart, the nurse will still be able to identify which client chart they belong to.

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which information? a. The physician's assessment and treatment b. Results of laboratory and diagnostic studies c. Nursing documentation and plan of care d. Information from other members of the health care team

a. The physician's assessment and treatment The medical history, physical examination, and progress notes record the findings of physicians as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment. The laboratory results will be in a different section of the health record and not typically in the medical history and treatment plan. Nursing documentation will be in the nursing section. Information from the other members of the health care team is found in the progress notes.

A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply. a. S: The nurse handling the transfer describes the client situation to the new nurse. b. S: The nurse discusses the client's symptoms with the new nurse in charge. c. B: The nurse gives the background of the client by explaining the client history. d. A: The nurse presents an assessment of the client to the new nurse. e. R: The nurse explains the rules of the new facility to the client. f. R: The nurse gives recommendations for future care to the new nurse in charge.

a. S: The nurse handling the transfer describes the client situation to the new nurse. c. B: The nurse gives the background of the client by explaining the client history. d. A: The nurse presents an assessment of the client to the new nurse. f. R: The nurse gives recommendations for future care to the new nurse in charge. Examples of using the SBAR technique are numerous. The nurse handling the transfer describes the client situation to the new nurse. The nurse gives the background of the client by explaining the client history. The nurse presents an assessment of the client to the new nurse. The nurse gives recommendations for future care to the new nurse in charge. The nurse does not explain the rules of the new facility to the client as part of the SBAR technique. The nurse would discuss the client's symptoms with the new nurse in charge as part of the "B" background, not the "S" situation.

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation? a. Source-oriented b. Problem-oriented c. PIE charting d. Charting by exception

a. Source-oriented A source-oriented record is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically, with the most recent entry being nearest the front of the record. Problem-oriented medical record (POMR) or problem-oriented record is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. PIE charting system is unique in that it does not develop a separate care plan. The care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified). In this documentation system, a client assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms (flow sheets). Client problems identified in these assessments are numbered, documented in the progress notes, worked up using the problem, intervention, evaluation (PIE) format, and evaluated each shift. Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes.

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? a. Subjective data should be included when documenting. b. Objective data are what the client states about the problem. c. The plan includes interventions, evaluation, and response. d. Abnormal laboratory values are common items that are documented.

a. Subjective data should be included when documenting. Subjective data should be included when using the SOAP format for documentation. Objective data are 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 provider's judgment of the situation, and abnormal lab values would be included in objective data.

A health care provider suggests that the nurse use the computer terminal that is available at the point of care or at the client's bedside. In what scenario is this most important? a. The client has had a sudden change in status needing immediate attention. b. The client is receiving ongoing medication therapy for a chronic disease. c. The client has enacted his or her rights and demanded to see all records and documentation as they occur. d. The client is being discharged and the nurse is providing discharge education.

a. The client has had a sudden change in status needing immediate attention. Computerized charting, which means documenting client information electronically, is most useful for nurses when a terminal is available at the point of care or bedside. These point-of-care (POC) systems allow for timely documentation that can be shared with multiple people and can reduce errors. This is extremely important and beneficial when a client's status has changed and frequent assessments are needed. While the POC system is efficient and can be used when administering medication or documenting discharge instruction, these are not the most probable cause for the suggestion from the provider. The client does have a right to review his or her medical records, but this would not be a reason to document in the POC system.

Which example may illustrate a breach of confidentiality and security of client information? a. The nurse provides information over the phone to the client's family member who lives in a neighboring state. b. The nurse provides information to a professional caregiver involved in the care of the client. c. The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. d. The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell.

a. The nurse provides information over the phone to the client's family member who lives in a neighboring state. Providing information over the phone to a family member without knowing whether or not the client wants that family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach of confidentiality, but providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.

Which documentation by the nurse best supports the PIE charting system? a. Vomiting 250 mL undigested food, antiemetic given, no further vomiting b. States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given c. Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg d. Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea

a. Vomiting 250 mL undigested food, antiemetic given, no further vomiting PIE charting includes the problem, intervention, and evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (problem), antiemetic given (intervention), no further vomiting (evaluation).

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? a. Write a narrative note in the designated nursing section. b. Place the narrative note chronologically after the respiratory therapist's note. c. Review the laboratory results under the physician section. d. Use a critical pathway to document the physical assessment.

a. Write a narrative note in the designated nursing section. Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the physician section. Critical pathways are not used to document physical assessments.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a. a client who is homebound and needs skilled nursing care b. a client whose rehabilitation potential is not good c. a client whose status is stabilized d. a client who is not making progress in expected outcomes of care

a. a client who is homebound and needs skilled nursing care Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.

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. a referral. b. a consultation. c. conferring. d. reporting.

a. a referral. Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: a. have the right to copy their health records. b. need to obtain legal representation to update their health records. c. can be punished for violating guidelines. d. are required to obtain health record information through their insurance company.

a. have the right to copy their health records. HIPAA affords clients the right to see and copy their health records, update their health records, and get a list of disclosures that a health care institution has made for the purposes of treatment, payment, and health care operations. Clients have the right to request a restriction on certain uses or disclosures and choose how to receive this health information. HIPAA includes punishments for anyone caught violating client privacy, but these punishments are not directed at the client because HIPAA was implemented to protect the privacy of an individual's health information.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: a. limiting abbreviations to those approved for use by the institution. b. using only abbreviations whose meaning is self-evident to an educated health professional. c. ensuring that abbreviations are understandable to clients who may seek access to their health records. d. using only those abbreviations that are defined in full at another location in the client's chart.

a. limiting abbreviations to those approved for use by the institution. In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? a. subjectivity b. objectivity c. organization d. reimbursement

a. subjectivity Quoting what the client is saying helps in the documentation of subjective data. Objective data are assessment data that may be directly observed by the nurse such as blood pressure. Organization is the structure of the documentation and does not relate to subjective data. Reimbursement is a distractor that doesn't relate to assessment data.

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse? a. "The hospital owns your records and does not have to allow you access while you are a client here." b. "I will have to review the policy that determines what procedure is in place for client access." c. "Let me open up the computer access so that you can see what information is of interest to you." d. "You may not understand all of the information and it will confuse you so I will help you decipher it all."

b. "I will have to review the policy that determines what procedure is in place for client access." Clients have the right to see their own medical records and request changes to documentation that may be in error. Most facilities have a policy in place for the client to obtain medical records and the nurse should ensure that the policy is followed by being familiar with that policy prior to giving the client free access to the record. The nurse should not demean the client by assuming that the information may be confusing. The nurse should not allow the client access to the computer while using the nurse's password or login information. While the hospital maintains responsibility for the record, the client has the right to see it.

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? a. "Let me get that for you." b. "Only authorized persons are allowed to access client records." c. "The provider will need to give permission for you to review." d. "I am sorry I can't access that information."

b. "Only authorized persons are allowed to access client records." The client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. The other answers are therefore inappropriate responses.

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation? a. Fill out an incident report. b. Attach a copy of the incident report to the chart. c. Stop the infusion and document the time. d. Report the error to the primary provider.

b. Attach a copy of the incident report to the chart. For legal reasons, the nurse should not attach a copy of the incident report to the chart. The nurse should, however, stop the infusion and document the time, report the error to the primary provider and nursing supervisor, and fill out an incident report.

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error? a. Immediately delete the incorrect documentation. b. Create an addendum with a correction. c. Contact information technology (IT) staff to make the correction. d. Contact the health care provider.

b. Create an addendum with a correction. If the nurse is using an EMR and the documentation cannot be changed, an addendum will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies. The health care provider does not need to be contacted to make a correction, but does need to be informed if this caused any direct harm or effects to the client.

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edematous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"? a. PIE b. FOCUS c. Narrative d. Exception

b. FOCUS The nurse used FOCUS charting, as it gives priority attention to the client's current or changed behavior. PIE charting occurs when the nurse records the client's progress under the headings of problem, intervention, and evaluation. Narrative charting content resembles a log or journal entry. Charting by exception is charting only abnormal assessment findings that deviate from a standard norm. Therefore, this nurse is not demonstrating PIE, narrative, or exception charting.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. a. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards b. Obscuring identifiable names of clients and private information about clients on clipboards c. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public d. Keeping record of people who have access to clients' records e. Making the names of clients on charts visible to the public

b. Obscuring identifiable names of clients and private information about clients on clipboards c. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public d. Keeping record of people who have access to clients' records Obscuring identifiable names of clients and private information about clients on clipboards; placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public; and keeping record of people who have access to clients' records are required under the Health Insurance Portability and Accountability Act (HIPAA), which is legislation that attempts to limit casual access to the identity of clients. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards and making the names of clients on charts visible to the public are violations of HIPAA, as these activities allow casual access to the identity of clients.

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? a. FOCUS charting b. SOAP charting c. PIE charting d. narrative charting

b. 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 client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy? a. Do not release any information to the insurance company. b. Use minimum disclosure policy to release the information. c. Refer the insurance agency directly to the client. d. Release the full medical record to expedite payment.

b. Use minimum disclosure policy to release the information. The nurse should use minimum disclosure policy to release the information, as per HIPAA regulations. It is inappropriate to not release any information to the insurance company, to refer the insurance agent directly to the client, and to release the full medical record to expedite payment.

A client's record can be more accurate if the nurse: a. charts at least every 6 hours. b. uses point-of-care documentation. c. summarizes client care at the end of the shift. d. delegates charting appropriately.

b. uses point-of-care documentation. Point-of-care documentation takes place as care occurs, thus enhancing accuracy. Today many facilities incorporate technology that is mobile and can be used immediately at the client's bedside for point-of-care documentation. The nurse should not delegate documentation, nor should it be left to the end of a shift. Documentation should be performed more than once every 6 hours.

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. a. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. b. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. c. "I don't feel well. I've been urinating often, and it burns when I urinate." d. Fever, possible urinary tract infection

c. "I don't feel well. I've been urinating often, and it burns when I urinate." a. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. d. Fever, possible urinary tract infection b. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. When using the SOAP format, the nurse would first document the subjective data (S: the client's complaint), objective data (O: abdomen, urine characteristics, temperature and contributing factors), assessment (A: caregiver's judgment about the situation—fever and possible urinary tract infection), and plan (P: what the caregiver is going to do—notify the physician, encourage fluids, and continue to monitor).

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in charting? a. "If I make an error, I can draw a red circle around it." b. "If I make an error, I have to rewrite the entire entry." c. "If I make an error, I draw a single line through it and put my initials by it." d. "If I make an error, I use white-out on it."

c. "If I make an error, I draw a single line through it and put my initials by it." When an error occurs, the nurse should draw a single line through the error and place his or her initials above it. If the nurse is using an EMR (electronic medical record), and the documentation cannot be changed - this will require an addendum.

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client? a. 8:00: Pt is resting in bed and appears to be comfortable. b. 0800: Resting in bed, eating some breakfast. Complains of headache. c. 0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. d. 0800: Side rails up, call light in reach. Bed in high position.

c. 0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. Pt is not an appropriate abbreviation for patient and it is understood that all entries are specific to the patient. Avoid the phrases "appears to be" and "seems to be," as they suggest uncertainty. Military time should be used to avoid confusion. Specific, detailed information should be included when possible, such as consumed 80% of breakfast and a reported pain level. Bed in high position is not appropriate for patient safety.

Which are appropriate actions for protecting clients' identities? Select all that apply. a. Orient computer screens toward the public view. b. Ensure that clients' names on charts are visible to the public. c. Document all personnel who have accessed a client's record. d. Place light boxes for examining X-rays with the client's name in private areas. e. Have conversations about clients in private places where they cannot be overheard.

c. Document all personnel who have accessed a client's record. d. Place light boxes for examining X-rays with the client's name in private areas. e. Have conversations about clients in private places where they cannot be overheard. Documenting all personnel who have accessed a client's record, placing light boxes for examining X-rays with the client's name in private areas, and having conversations about clients take place in private where they cannot be overheard are useful strategies to limit casual access to the identity of clients and health informatics. Orienting computer screens toward the public view and visibly displaying clients' names on charts are incorrect, as these are breaches of patient confidentiality.

Which is a drawback to the type of documentation known as charting by exception? a. Interference with standardized assessments b. Less interdisciplinary communication c. Issues related to high-quality care should a negligence claim arise d. Increased time required to document information

c. Issues related to high-quality care should a negligence claim arise Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes. Benefits of this approach include less time needed for charting (freeing more time for direct client care), a greater emphasis on significant data, easy retrieval of significant data, timely bedside charting, standardized assessment, greater interdisciplinary communication, better tracking of important client responses, and lower costs. However, a significant drawback to charting by exception is its limited usefulness when trying to prove that high-quality, safe care was given if a negligence claim is made against a nurse.

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method? a. Source-oriented method b. PIE charting method c. Problem-oriented method d. Focus charting method

c. Problem-oriented method The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care. Progress notes clearly focus on client problems. Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically. PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). Focus charting method brings the focus of care back to the client and the client's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a client and client care.

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? a. Problem-oriented recording gives clients the right to withhold the release of their information to anyone. b. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. c. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. d. Problem-oriented recording has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care.

c. 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 health care providers is an advantage of problem-oriented recording and is therefore correct. Giving clients the right to withhold the release of their information to anyone is a beneficial disclosure and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving clients' problems among caregivers and having numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care are examples of source-oriented recording.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? a. Dialogue b. Documentation c. Reporting d. Verification

c. Reporting Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. Some facilities may use encrypted (protected) software programs such as Share Point or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? a. Disclosing client health information for research purposes after obtaining permission from the client's physician b. Releasing the client's entire health record when only portions of the information are needed c. Submitting a written notice to all clients identifying the uses and disclosures of their health information d. Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information

c. Submitting a written notice to all clients identifying the uses and disclosures of their health information Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the physician's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations.

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? a. The client is receiving sufficient relief from pain medication, stating no pain in either knee. b. The client appears comfortable and is resting adequately and appears to not be in acute distress. c. The client reports that on a scale of 0 to 10, the current pain is a 3. d. The client appears to have a low tolerance for pain and frequently reports intense pain.

c. The client reports that on a scale of 0 to 10, the current pain is a 3. The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply. a. what the client watched on television during the shift b. what time the nurse will return for the next shift c. any abnormal occurrences with the client during the shift d. identifying demographics, including diagnosis e. current orders

c. any abnormal occurrences with the client during the shift d. identifying demographics, including diagnosis e. current orders Any identifying information regarding the client's demographics such as name, age, gender, diagnosis, and so on should be communicated to the oncoming nurse caring for the client. Any current orders or orders that have not been completed during the shift should be communicated as well. The oncoming nurse should be informed of any occurrences with the client that have been out of the norm and what actions, if any, were taken. Information about what the client watched for entertainment is not of relevance and should be eliminated from the report, as well as what time the nurse will be working next.

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best? a. "The UAP will tell me what the vital signs are, and I will record them in the record so the health care provider can review them." b. "Vital signs do not need to be recorded unless they are abnormal." c. "The UAP logs in under my name and documents the vital signs." d. "The UAP is able to log in and enter the information so all members of the health care team can see it."

d. "The UAP is able to log in and enter the information so all members of the health care team can see it." Each person who makes entries in the client's electronic health record (EHR) is responsible for the information he or she records and can be summoned as a witness to testify concerning what has been documented. Although the licensed registered nurse has accountability, the UAP can document data that has been collected in the EHR. It is not appropriate to document for someone else, and all users should always log out of the computer prior to allowing another person to document.

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator? a. Talking directly to the translator facilitates the transfer of information. b. Talking loudly helps the translator and the client understand the information better. c. It is always okay to not use a translator if a family member can do it. d. Translators may need additional explanations of medical terms.

d. Translators may need additional explanations of medical terms. When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times.