Chapter 19 Documenting and Reporting

A nurse is documenting information about a patient in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)

minimum data set

A student has reviewed a patients chart before beginning assigned care. Which of the following actions violates patient confidentiality?

writing a patients name of the student care plan.

Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry?

A.Jones, RN

What is the primary purpose of an incident report?

means for identifying risks

A physician order read up ad lib. What does this mean in terms of patient activity?

May be up as desired.

Which of the following are example of breaches of patient confidentiality? Select all that apply:

A nurse discusses a patient with a coworker in the elevator A nurse shares her computer password with a relative of a patient. A nurse updates the employer of a patient regarding the patients return to work. A head nurse accesses the medical records of a nurse on her shift to check her condition.

Which of the following are examples of incidental disclosures of patient health information that are permitted? Select all that apply:

A nurse working in a physicians office puts out a sign-in sheet for incoming patients Two nurses are overheard talking about a patient through the door of an empty patient room. A nurse calls out the name of a patient who is seated in the waiting room.

Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse?

Charting by exception

A nurse uses informatics to plan nursing care for a patient. Which three terms best describes this science as it is applied to nursing?

Data, information, knowledge

Which of the following data entries follow the recommended guidelines for documenting data?

Following oxygen administration, vital signs returned to baseline.

What part of the patients record is commonly used to document specific patient variables, such as vital signs?

Graphic record

A patient asks to see his medical record (Chart) how would the nurse respond?

I will get your chart and provide you the privacy to read it.

A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next?

Individualize it to the specific patient.

A group of nurses visits selected patients individually at the beginning of each shift. What are these procedures called?

Nursing care rounds

What is the nurses best defense if a patient alleges nursing negligence?

Patient Records

Which of the following information would a nurse include as part of a minimum data set when using electronic medical records? Select all that apply:

Patient Sex patient admission date patient insurance patient ethnicity

A nurse organizes patient data using the SOAP format. Which of the following would be recorded under S of this acronym?

Patient complaints of pain.

A nurse is documenting the intensity of a patients pain. What wold be the most accurate entry?

Patient states pain is a 9 on a scale of 1 to 10

In what type of documentation method would a nurse document narrative notes in a nursing section?

Source-oriented record

Which of the following abbreviations are on the list of the Joint Commissions DO NOT USE abbreviations? Select all that apply:

U (unit) QU (daily) > (greater than)

In which of the following cases should a progress note be written? Select all that apply.

When admitting a patient. When receiving a patient postoperatively. When a procedure is performed.

What is the primary purpose of the patient record?

communication

What is the primary purpose of focus charting?

patient concerns

Which one of the following methods of documentation is organized around patient diagnoses rather than around patient information?

problem-oriented medical record (POMR)