Chapter 4: Documentation and Interprofessional Communication
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. Rationale: Additional questions and assessments would be necessary to validate the apparent inconsistency between the client's self-report and the nurse's observations. Consulting the MAR would be of little benefit, and having him repeat his statement does not provide sound validation.
Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline." Rationale: The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. The nurse should also avoid generalizations such as "seems comfortable today." The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner.
A client asks to see his medical record (chart). How would the nurse respond?
"I will get your chart and provide you with privacy to read it.' Rationale: According to the Health Insurance Portability and Accountability Act (HIPAA), clients have a right to see and copy their health records.
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 Rationale: Not every piece of data you collect must be verified. For example, you would not need to verify or repeat the client's pulse, temperature, or blood pressure unless certain conditions exist. The blood pressure reading, pulse rate, and temperature listed in the answer choices are all within the normal range given the contexts provided. A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and who appears to be of normal weight, however, would be cause for validation, as there is a significant gap between the finding of the client's weight and the client's appearance.
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 Rationale: Flow charts help staff record and retrieve data for frequent reassessments. Flow charts help streamline documentation and prevent needless repetition of data.
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 Rationale: When reporting over a telephone, ask the receiver to read back what he or she heard you report and document the phone call with time, receiver, sender, and information shared. It would not be feasible to communicate face to face or provide documentation when speaking on the phone. Also, it would not be feasible or appropriate to have the attending physician speak with the other nurse, as the physician may not be available and would not likely be able to clarify the first nurse's assessment findings anyway.
During the admission assessment, the nurse notes the client has cuts to her face and bruises on her chest and back. Which of the following demonstrates the most appropriate documentation of these findings?
Dark purple-blue area on the right side of chest and on right lower back. Open areas on the left side of the lower lip and above right eye. Rationale: Documentation needs to be clear and specific. Documentation should describe and provide a location of the areas. Documentation should not include any assumptions or judgements.
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 Rationale: With charting by exception, only abnormal findings are documented. The only abnormal finding listed is the client's decreased range of motion.
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 Rationale: The medical record can be used as a legal document to provide evidence of wrongdoing. Quality assurance is conducted to determine whether standards of care are provided to clients and documented in the medical record. Various members of the healthcare team document in the medical record to communicate information and make care decisions and plan for client discharge. Information in the client's medical record is used to determine reimbursement by Medicare, Medicaid, workers' compensation insurance, and third-party insurance companies for care.
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 Rationale: Some institutions may use assessment forms that are focused on one major area of the body for clients who have a particular problem. Examples include cardiovascular or neurologic assessment documentation forms. An assessment flow chart allows for rapid comparison of recorded assessment data from one time period to the next. Progress notes may be used to document unusual events, responses, significant observations, or interactions because the data are inappropriate for flow records. The nursing minimum data set form has a cued format that prompts the nurse for specific criteria; it is usually computerized and is commonly used in long-term care facilities.
The nurse prepares information to provide to the nurse scheduled to work the next shift. Which type of communication is the nurse preparing?
Handoff report Rationale: Communication that occurs when one health care provider transfers client care responsibilities to another care provider is referred to as a "handoff." The nurse may be providing a verbal review however this is not what the action is called. An end-of-shift note would be written. A discharge summary would be written at time of a client's discharge from the facility.
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:
Have the right to copy their health records. Rationale: HIPAA affords clients the right to see and copy their health records, update their health records, and get a list of disclosures a healthcare institution has made for the purposes of treatment, payment, and healthcare operations. Patients 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.
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 Rationale: Research has shown that EHRs can improve the continuity of care that clients receive. EHRs are not noted to increase the influence of the nursing profession or reduce workload. EHRs are a form of documentation, not an elimination of documentation.
What statement about batch charting is most accurate?
It contributes to many potential errors. Rationale: Batch charting (waiting until the end of shift or until all clients have been assessed to document) contributes to many potential errors. If you wait to record, you may forget important information or chart assessment data on the wrong client.
Examples of objective data include all the following except:
Itchy skin Rationale: Objective data are information obtained during the physical examination. They include all data gathered by inspection, palpation, percussion, and auscultation. Coughing is audible to the examiner, foul-smelling discharge can be smelled, and reddened skin can be noted on inspection. Itchy skin is a subjective report from the client experiencing it.
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 Rationale: The risk assessment report provides risk scores on sepsis, pressure ulcers, falls, abnormal laboratory reports, and other criteria of interest. This permits early intervention and saves lives. Frequently, clients show clinical signs of deterioration, but health care providers fail to respond for 24 hours before a critical adverse event. The computerized risk assessment report does not tell the physician when a change in client care is necessary; it does not inform the laboratory when machines need to be recalibrated, nor does it confirm pharmacy reception of client orders.
The nurse is caring for a client with influenza symptoms and is documenting the initial and ongoing assessment database. What would the nurse emphasize as the major rationale for this action?
Promoting communication between disciplines Rationale: The initial and ongoing assessment documentation database establishes a way to communicate with multidisciplinary team members. With computer-based documentation systems, this database can link to other documents and health care departments, thus eliminating repetition of similar data collection by other health team members. Through this communication, fragmentation of care ultimately may be reduced and incorrect conclusions may be minimized.
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 via telephone. How would the nurse best validate the new order?
Read the order back to the health care provider for confirmation. Rationale: When reporting over a telephone, the care provider should ask the receiver to read back what they heard you report and document the phone call with time, receiver, sender, and information shared. The other listed actions are insufficient to validate the data.
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 Rationale: The most appropriate method of validation in this case would be to simply retake the client's blood pressure with a different sphygmomanometer and stethoscope. Given the nurse's work experience, it is unlikely that the discrepancy is due to improper technique, thus having the physician take the client's blood pressure is not warranted. Given the client's long history of hypertension and that his weight has not changed, it seems unlikely that the discrepancy could be explained by improved diet or exercise.
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 Rationale: Verbal communication of a change in a client's condition would be most effective if the nurse used SBAR as it provides a standardized format and structure for communication. PIE, DAR and SOAP are all types of progress notes.
The nurse is reviewing a SOAPIE note in the client'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 Rationale: This is an example of subjective assessment data because it contains data verbally provided by the client. Objective data are data cues the nurse can observe. Analysis involves the identification of client problems based on the subjective and objective data. The plan outlines the course of action taken to address the problem. Evaluation involves a determination of whether the plan and attainment of expected client outcomes.
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 Rationale: The nursing history and physical examination are also known as subjective and objective data. The nurse interprets this information and draws inferences from it. Observation and inspection are techniques used to perform the physical exam. Data are the information obtained from assessment; the results would be similar to the outcomes achieved by a client.
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. Rationale: As per HIPAA regulations, it is important to block the type of information that personnel in various departments can retrieve. Laboratory assistants can retrieve information from the medical records, but they cannot view information in the client's personal history. Even if the laboratory assistant had the correct access number and the password or was trying to view archived data, he or she would not have been able to access a client's personal history.
The nurse is reviewing and analyzing data from the initial assessment of a newly admitted client who is a 79-year-old man. What assessment finding most clearly indicates a need for further data?
The man has a diffuse rash on his torso. Rationale: The nurse should know the onset, precipitating factors, and course of the rash in order to plan appropriate interventions and referrals. The other data do not suggest an immediate need for more data.
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 Rationale: The primary reason for documentation of assessment data is to promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care. Although documentation may protect a practice from liability, help avoid penalties, and aid the nurse's recall of client information, none of these is the primary reason for documentation.
Which example may illustrate a breach of confidentiality and security of client information?
The nurse provides information over the phone to the client's family member who lives in a neighboring state Rationale: Providing information over the phone to a family member without knowing whether or not the client wants the 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 in confidentiality, while providing information to a professional not involved in the care of the client is a breach in confidentiality. Patient 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.
A nurse is instructing the nursing student on strategies for reducing high-risk errors in documentation. Which examples should the nurse include when teaching the nursing student? Select all that apply.
The nurse takes and records the client's heart rate before administering digoxin. The nurse notes the return of bowel sounds following the client's surgery. The nurse administers pain medication when the client reports a pain rating of 7. Rationale: Strategies for reducing high-risk errors in documentation include measuring the client's heart rate before the administration of digoxin, noting the return of bowel sounds following surgery, and administering pain medication when the client's pain rating is 7. High-risk errors in documentation include forgetting to document a complete assessment and documenting interventions not performed.
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 Rationale: Avoid documenting with general nondescriptive or nonmeasurable terms such as normal, abnormal, good, fair, satisfactory, or poor. Instead, use specific descriptive and measurable terms (e.g., 3 inches in diameter, red excoriated edges, with purulent yellow drainage) about what you inspected, palpated, percussed, and auscultated.
A nurse is comparing the subjective data and objective data obtained from an assessment of a client who is thought to have hepatitis A. This nurse's comparison will achieve what benefit to this client's care?
Validation of data Rationale: The nurse compares objective and subjective data to determine discrepancies and validate the data obtained to ensure that the information is accurate and complete. Missing data would need to be validated. From this validation, the nurse can then formulate nursing diagnoses. The form used for documentation varies from agency to agency and is unrelated to the comparison of subjective and objective data.
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 Rationale: Quality assessment data remain confidential, accurate, concise, complete, organized, and timely. Findings are not biased but factual.
If the nurse makes an error while documenting findings on a client's record, the nurse should
draw a line through the error, writing "error" and initialing. Rationale: Errors in documentation are usually corrected by drawing one line through the entry, writing "error," and initialing the entry. Never obliterate the error with white paint or tape, an eraser, or a marking pen. Keep in mind that the health record is a legal document.
A 54-year-old client is receiving a follow-up assessment in a clinic, following abnormal findings on her recent mammogram. Which of the following statements best reflects appropriate documentation by the nurse?
"Client has unkempt appearance and avoids eye contact" Rationale: Unkempt appearance and avoiding eye contact are specific observations that are easily understood. The nurse cannot diagnose depression. "Lower back pain" represents incomplete data, and describing lung sounds as "good" is not using appropriate terminology.
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." Rationale: Use phrases instead of sentences to record data. For example, avoid recording: "The client's lung sounds were clear both in the right and left lungs." Instead record: "Bilateral lung sounds clear."
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 Rationale: Documentation should be concise and precise. The nurse should record what the client tells her in detail. Nurses should not make judgments or diagnosis about the information gathered until all data has been collected and validated. The use of the statement "within normal limits" should not be used-the nurse should document the actual data that was collected.
After performing a comprehensive assessment on a new client, the nurse documents the following findings. Which documentation follows acceptable documentation guidelines?
Client states, "I don't want to eat or do anything." Rationale: Entering what the client states using quotations is the most accurate way to document. Documentation must be objective, nonjudgmental, and clear; subjective information should be documented using quotations. Stating the client "seems" depressed is a judgment. Although the nurse documenting "When asked, the client refused to eat or get out of bed" is stating similar findings as documenting "Client states 'I don't want to eat or do anything,'" the latter is more concise. Instead of documenting "Client stated they were depressed because they lost their job," the nurse should have quoted the client directly, such as "I am depressed because I lost my job," to make the documentation clearer.
A nurse has completed assessing a client and now must validate the collected data. What are the steps that the nurse should follow? Select all that apply.
Decide whether the data require validation. Determine ways to validate the data. Identify areas where data are missing. Rationale: The steps involved in validation of data include deciding whether the data require validation, determining ways to validate the data, and identifying areas where data are missing. The nurse need not verify every piece of data that was assessed unless there are discrepancies or gaps in the data collected. The nurse need not repeat all objective assessments, unless they are abnormal or inconsistent with other findings.
Why should the nurse document assessment findings?
Determine the educational needs of the client Rationale: One of the reasons the nurse should document assessment findings to determine the educational needs of the client. Documentation acts as a source of information to help diagnose new problems rather than eliminating the possibility of diagnosing new problems. Documentation ensures that the information documented is accessible to all members of the health care team, not just the nurse; this enables effective communication between the team members. Delays in carrying out the plan of care are prevented by documentation of assessment findings.
Why is accurate and effective documentation most important?
Documentation constitutes a legal record. Rationale: The client record serves as a legal document recording the client's health status and any care he or she receives. The client record can be used in civil or criminal courts to provide evidence of wrongdoing.
A client is being discharged from the hospital after a below-the-knee amputation. The nurse has completed the discharge and gives a copy of the discharge summary with client teaching and medications to the client. The nurse understands the importance of doing a good assessment prior to discharge for which of the following purposes:
Identify necessary resources and strategies for successful home management. Rationale: Assessment of the client prior to discharge should indicate that he or she is stable and has received teaching regarding medications and follow-up care. It is used to identify necessary resources and strategies for successful home management. Such assessment is not done to increase the level of competence of the nurse, nor to complete the chart or make the client feel more comfortable. The assessment information is also useful for social work, physical therapy, and occupational therapies, and follow-up care by the nurse and provider when returning to the outpatient setting.
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. Rationale: When rounds occur at the bedside and include the client, the nurse facilitates active participation to set goals and plan care. Such rounds usually take more time. Freeing up the report room is not a benefit of walking client rounds, nor does this method allow for much more exercise than what is normal when caring for clients.
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. Rationale: Under HIPAA regulation, health care agencies need to submit a written notice to all clients identifying the uses and disclosures of their health information, such as to third parties for use in treatment or payment for services. The physicians, auditors, and the health authorities do not have the right to share any client information without the client's written consent.
The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?
Reassess blood pressure Rationale: The nurse can delegate the monitoring and documenting of specific assessments to UAPs; but the nurse always retain the responsibility to interpret delegated assessment data to evaluate the client's condition. The nurse should retake the blood pressure immediately as it is abnormally low for this client. Having the UAP retake the blood pressure does not allow the nurse to evaluate the client or assess the accuracy of the UAP's ability to take a blood pressure. The physician should not be notified until the blood presser has been reassessed.
A nurse is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect? Select all that apply.
The client's occupation The client's family history of cancer The client's weight-lifting routine Rationale: Subjective data include information that the client or significant others tell the nurse and typically consist of biographic data, present health concern(s) and symptoms, personal health history, family history, and lifestyle and health practices information. Objective data are what the nurse observes through inspection, palpation, percussion, or auscultation.
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." Rationale: Answer C is both precise and objective, while stating the client is "anxious" in answer A is not objective. Labelling chest sounds as "abnormal" or simply describing pain as "sharp" in answers B and D both indicate a lack of detail.
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." Rationale: The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a complaint of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.
A nurse is documenting the intensity of a client's pain. What would be the most accurate entry?
"Patient states pain is a 9 on a scale of 1 to 10." Rationale: Information should be documented in a complete, accurate, relevant, and factual manner. Avoid interpretations of behavior, generalizations, and words such as "good."
Which strategy reduces documentation errors? Select all that apply.
Document client information immediately. Designate a person to document during emergencies. Organize client data logically, using a timed sequence. Rationale: Strategies that reduce documentation error include documenting client information immediately, organizing client data logically using a timed sequence, and designating a person to document during emergencies. Patient information should be documented without ambiguous terminology and immediately following assessment of individual clients.
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. Rationale: HITECH was signed into law as part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and meaningful use of health information technology (HIT). Since this Act was adopted, there has been a slow but steady increase in the use of electronic health records (EHRs) by health care agencies and primary health care providers. The Minimum Data Set is limited to long-term care settings, and interdisciplinary collaboration does not meet the specific criteria of HITECH. Verbal handoffs are not precluded by HITECH.
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 Rationale: One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.
The Health Insurance Portability and Accountability Act mandates client confidentiality. What methods of protecting client confidentiality are included?
Never sharing computer passwords Rationale: Methods of protecting confidentiality include never sharing computer passwords and never leaving a computer with client information unattended. They do not include keeping all the information on computers, keeping client information readily accessible for families, or discussing clients with other health care personnel.
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 Rationale: 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 has been prescribed a new medication. What action is most important for the nurse to take prior to administration?
Verify client allergies to medications. Rationale: Prior to administering new medications to a client, the nurse must first verify allergies with the client. If the nurse feels the medication order is inappropriate, the nurse will clarify the order. There is not enough information provided to question or clarify this new medication order, or to check the client's vital signs or laboratory values.