Chapter 19 Documenting & Reporting

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR? "I am concerned that the client might be exhibiting sepsis." "The client's temperature has been 102°F (38.9°C) for the last 6 hours." "The client was admitted today with a urinary tract infection." "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

Which agency is responsible for monitoring compliance to Health Information Technology for Economic and Clinical Health (HITECH)? Centers for Medicare and Medicaid Services The Joint Commission World Health Organization Department of Social Services

Centers for Medicare and Medicaid Services

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report? Incident report Nurse's shift report Transfer report Telemedicine report

Incident report

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate? Explain the reason why information cannot be disclosed. Verify the insurance coverage before giving information. Refer the parent to the physician providing care. Mediate a meeting between the parent and client.

Explain the reason why information cannot be disclosed.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? It documents assessments on separate forms. It records progress under problems, intervention, and evaluation. It provides and refers to a client's problem by a number. It provides quick access to abnormal findings.

It provides quick access to abnormal findings.

Which abbreviation is correct for use in documentation? PO Sub q Per os BT

PO

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

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

A nurse helps a client who has cystic fibrosis prepare a stand-alone personal health record. Which statement by the nurse best explains this type of information? "You can fill in information from your own records and store it on your computer or the Internet." "You can link your record to a specific health care organization's electronic health record system." "Your health care provider is obligated to read your personal health record and share it with your insurance provider." "Your entire health care team may access and securely share your vital medical information electronically."

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

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

a client who is homebound and needs skilled nursing care

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards 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 Keeping record of people who have access to clients' records Making the names of clients on charts visible to the public

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 Keeping record of people who have access to clients' records

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. S: The nurse handling the transfer describes the client situation to the new nurse. S: The nurse discusses the client's symptoms with the new nurse in charge. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse explains the rules of the new facility to the client. R: The nurse gives recommendations for future care to the new nurse in charge.

S: The nurse handling the transfer describes the client situation to the new nurse. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse gives recommendations for future care to the new nurse in charge.

The nurse is completing documentation for a newly admitted client. Which entries should the nurse include in charting? Select all that apply. The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. "I feel something is going on the client isn't telling me." The client was overheard telling a family member about more bleeding than reported The dressing has a 5 cm area of bloody drainage The client's pupils are equal, reactive, to light and accommodation

The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. The client was overheard telling a family member about more bleeding than reported The dressing has a 5 cm area of bloody drainage The client's pupils are equal, reactive, to light and accommodation

term-4A 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? data base problem list plan of care progress notes

progress notes

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information? Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." Client states expecting some pain, but it is more severe than anticipated. Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. Client is requesting pain medications, is grimacing, and is diaphoretic.

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

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

FOCUS

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records? Problem-oriented recording gives clients the right to withhold the release of their information to anyone. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. 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.

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

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? FOCUS charting SOAP charting PIE charting narrative charting

SOAP charting

What information should the nurse document in the medication record when administering a non-narcotic pain medication? Select all that apply. Time Dose Reason given Effectiveness of medication Vital signs

Time Dose Reason given Effectiveness of medication

The nurse is orienting a new graduate nurse and reviewing documentation. Which documentation performance would include best practices for charting? Select all that apply. Use long narratives to be sure that the documentation is understood. Always use complete sentences. Use only approved abbreviations. Always use the client's name and words referring to the client in each entry. Use partial sentences and phrases.

Use partial sentences and phrases. Use only approved abbreviations.