Chapter 4: Documentation and Interprofessional Communication
While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding?
"Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm."
The nurse is documenting client care. Which nursing assessment note would be most appropriate?
"Client voices concerns about being able to change abdominal dressings at home."
During a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?
"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."
Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline."
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry?
"Patient complaining of abdominal pain rated 8/10."
The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear."
A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered? Select all that apply.
- A description of a large bruise on the client's thigh - The client's weight - The presence of a lump in the client's breast discovered on palpation
Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?
A client has ask a nurse if he can read the documentation that his physician wrote in his chart.
A nurse is working in a health care facility that is using charting by exception. Which of the following would the nurse expect to document?
Aching, burning pain in lower back
A nurse has completed a client's initial assessment and is now interpreting and making inferences from the data. The nurse is involved in which phase of the nursing process?
Analysis
The nurse assesses all assigned patients and sits in the nursing station to document assessment data for all patients. This is an example of:
Batch charting
Abnormal assessment findings are clearly outlined in which documentation format?
Charting by exception
A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document?
Decreased range of motion in right shoulder
Quality assurance is one purpose of the medical record. An audit can be done to determine that the health care facility is providing and documenting certain standards of care. The following groups or people may conduct an audit. Check all that apply.
Department of Health Joint Commission Facility itself
Why is accurate and effective documentation most important?
Documentation constitutes a legal record.
A hospital is revising the policies and procedures surrounding documentation in an effort to align practices with the Health Information Technology for Economic and Clinical Health (HITECH) Act. How can the requirements of this legislation best be met?
Increase the use of electronic health records (EHRs) in the hospital.
An audit of a hospital unit's incident reports reveals that several errors have resulted from incomplete or inaccurate information during change-of-shift handoff. In order to prevent such errors, what practice should be encouraged on the unit?
Involve as few people as possible in the verbal report.
When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason?
It becomes the foundation for the entire nursing process.
What statement about batch charting is most accurate?
It contributes to many potential errors.
The nurse manager is implementing walking client rounds for the change-of-shift reports. One benefit of this type of reporting over others is:
It facilitates active participation of clients.
The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes
A health care agency has been asked to compensate a client as per a lawsuit filed against it for not following the Health Insurance Portability and Accountability Act (HIPAA) regulations. Which of the following situations is a HIPAA violation?
Not informing a client in writing of the purpose of sharing his or her personal details.
A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?
Progress notes
The nurse is reviewing the patient's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the patient's status?
Progress notes
A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Repeating the measurement with a different sphygmomanometer and stethoscope
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?
SBAR
Mistakes in charting can be costly to both the client and nurse. The Joint Commission has listed a primary cause for these mistakes as a failure in communication. Life-threatening errors in health care have been labeled as which of the following:
Sentinel events
A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?
The laboratory assistant can only retrieve medical records but cannot view the details.
Which example may illustrate a breach of confidentiality and security of patient information?
The nurse provides information over the phone to the patient's family member who lives in a neighboring state
The nurse uses the SBAR model when reporting on clients at the change of shift. This type of report incorporates what part of the nursing process?
assessment
In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed
focused
A legal nurse consultant explains to a group of nursing students that the medial record serves what purpose? Select all that apply.
• Determining eligibility for reimbursement • Legal document of care • A method to gather research data • Promoting effective communication between caregivers
How does the client's medical record affect financial reimbursement?
• Insurance companies audit client records to ensure that billing is accurate
A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply):
• accurate • organized • complete • timely • concise
Nurses are aware that "handoff" can significantly increase the risk for errors. Common examples of "handoffs" are as follows (check all that apply):
• when a patient is transferred from the PACU to the floor • when a nurse leaves for lunch • at change of shift
After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?
To communicate effectively with other health care team members
Which of the following examples of documentation best exemplifies sound clinical documentation practices?
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation?
A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight
During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?
"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."
A nurse is providing a verbal update to a client's primary care provider because of the client's worsening nausea. When using an SBAR format to provide a report, the nurse should complete the report with which of the following statements?
"I think this client would benefit from an antiemetic."
During an accrediting agency visit, it is found that some patient care standards are not being met. Where should problem solving occur in this instance?
Facility level
The hospital where a nurse works is converting from a paper-based documentation system to a computer-based one. The nurse recognizes that which of the following are advantages of computer-based over paper-based systems? Select all that apply.
- Elimination of redundant data collection by other health care team members - Increased likelihood that clients will receive life-saving treatment - Potential lowered risk of hospital-acquired infections - Ability to link the client's health record to other documents
The nursing instructor is teaching about the importance of good communication and accuracy when documenting on the client chart. Some things that are high-risk errors in documentation are the following: (Check all that apply.)
- Performing an inadequate admission assessment - Failing to record changes in a client's condition - Charting in advance - Falsifying client records
A nurse is recording some vital signs in a 12-year-old girl's chart when the girl asks why the nurse is writing all that information down. Which of the following should the nurse mention to this client as reasons for documenting assessment findings? Select all that apply.
- To prevent delays in carrying out the plan of care - To determine the educational needs of the client
A nurse is in the elevator at the hospital. The nurse overhears another nurse laughing and making jokes about a client. Why is this situation a breach of confidentiality?
All client information is private and confidential
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use?
An assessment flow chart
A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?
Ask the other nurse to read back what first nurse reported
The nurse is about to leave the floor for her lunch break. Before leaving she must report using the SBAR model to the nurse who is to care for the patient during her absence. She tells the nurse, "The patient was admitted 8 hours ago after spending the night in the ER with abdominal and back pain. He has had numerous tests; results indicate that he has gallstones. He is scheduled for surgery tomorrow." What part of the SBAR model does this information represent?
Background
While gathering a nursing history about a client's previous hospitalizations and surgeries, the nurse finds out that this is the client's first hospitalization and that he hasn't had any surgeries. The nurse would document which of the following?
Client denies prior hospitalizations and surgeries
While the nurse performs the initial assessment, the client states "This is my first hospitalization and I have had no previous surgeries." How would the nurse document this information?
Client denies prior hospitalizations and surgeries
A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?
Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.
Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?
Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10
A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?
Cued or checklist forms
A group of nursing students are reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes?
It provides a chronologic source of client assessment data.
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
The nurse documents a blood pressure value for the patient without taking the patient's blood pressure. This is an example of:
Falsifying the patient record
A client is having frequent blood pressure and blood glucose measurements to regulate an insulin infusion. Which type of documentation should the nurse use for this data?
Flow sheet
A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?
Focused
A nurse is working on a unit for clients with neurological conditions. Which assessment form would the nurse most likely use to document assessment data?
Focused assessment form
A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data?
Focused assessment form
On reviewing a client's database following a physical examination, a nurse realizes that the client's weight has been steadily increasing over her past three visits. What follow-up question would be best for the nurse to pose to the client based on this finding?
Has your diet or exercise changed significantly in the past year?
A nurse receives lab results on a client that show that the client is pregnant. The client says that this is impossible, however, because she is still breastfeeding her 1-year-old son. Which of the following would be appropriate ways for the nurse to validate the positive finding for pregnancy? Select all that apply.
Have the client take a different pregnancy test
The nursing manager explains to the nurses that it is important for the clients to be able to access their own medical records and the new electronic health record system will provide that opportunity. The nurse would identify which of the reasons this is so important?
Health care providers can receive significant incentive payments
The nurse is reviewing the patient's medical record. Which does the nurse recognize as accurate documentation?
Hyperactive bowel sounds are heard in all four quadrants.
There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many caregivers questioning the rationale for this change in practice. What potential advantage of EHRs should administrators cite?
Improved continuity of care
There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many health care providers questioning the rationale for this change in practice. What potential advantage of EHRs should administrators cite?
Improved continuity of care
The nurse manager is implementing walking patient rounds for the change-of-shift reports. One benefit of this type of reporting over others is:
It facilitates active participation of patients.
A group of nursing students is reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes?
It provides a chronologic source of client assessment data.
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
It provides quick access to abnormal findings.
A computerized risk assessment report correlates data and provides scores on various aspects of clients in the health care facility. Why would this be beneficial for client care?
Notifies health care providers when clients show clinical signs of deterioration.
A nurse is conducting client assessments in a long-term care facility. The manager of the facility has requested that the clinical staff use assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas, and time, so that they can compare their results with other long-term care facilities in the nation. Which form should the nurse use?
Nursing minimum data set
What is the name of the information program mandated by the federal government for the initial and ongoing assessment of Medicare and Medicaid clients in the homecare setting?
OASIS
When performing an assessment, which of the following would be most helpful in validating a client's chief complaint?
Objective data
The nurse is reviewing a SOAPIE note in the patient's medical record. The nurse recognizes that "States no longer nauseous and would like something to eat" is which part of the SOAP note.
Subjective
A client has illuminated his call light and tells the nurse that he is having "ten out of ten" pain. The nurse's initial inspection reveals that the client is watching videos on his tablet computer and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain?
Perform further assessments addressing various aspects of the client's pain.
The nurse responds to a call light for a client rating their pain "ten out of ten." The nurse's initial inspection reveals the client is watching videos and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain
Perform further assessments addressing various aspects of the client's pain.
The nurse documents data immediately after assessing the client. This is an example of:
Point-of-care documentation
The nurse documents data immediately after assessing the patient.
Point-of-care documentation
A client's pain has become increasingly severe, but the client has received the maximum doses of analgesics. The nurse is receiving a new analgesic order from the health care provider. How would the nurse best validate the new order?
Read the order back to the health care provider for confirmation.
A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The patient's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Repeating the measurement with a different sphygmomanometer and stethoscope.
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 nursing implementing?
SOAP charting
Mistakes in charting can be costly to both the patient and nurse. The Joint Commission has listed a primary cause for these mistakes as a failure in communication. Life-threatening errors in health care have been labeled as which of the following:
Sentinel events
A novice nurse is preparing for a physical examination of a client with neurological issues. The nurse takes a copy of the practice's standard assessment form and heads to the examination room, where the client is already waiting. A senior nurse notes the novice nurse's actions and says, "Here, use this form instead; it's an assessment form specifically for the neurological system." This second form is an example of which type of form?
Specialty area assessment form
A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following?
Subjective data and objective data
After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information as which of the following?
Subjective data and objective data
A nurse is documenting a skin condition that she has observed while examining a client. Which of the following descriptions would be most appropriate to include in the client's chart?
Three lesions, 5 mm in diameter, producing purulent yellow drainage on the client's right anterior forearm
What is an appropriate guideline for the nurse to follow when documenting assessment findings on a client?
Use phrases instead of sentences to record data
A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?
Use phrases instead of sentences to record data.
A client who had a mastectomy is being discharged home on postoperative day 1. Knowing that the client lives alone, which data would be most important for the nurse to validate for this client?
What support systems are in place to assist the client
The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations?
When communicating a patient's change in condition to the patient's physician.
A nurse is caring for a client who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called:
charting by exception
What information concerning a client's respirations should the nurse record after completing a general physical assessment?
rate, rhythm, and depth of respirations taken for a full minute
A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered?
• A description of a large bruise on the client's thigh • The client's weight • The presence of a lump in the client's breast discovered on palpation
