Chapter 4 Validating and Documentation data

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? a) Assessment flow chart b) Nursing minimum data set c) Focused d) Progress notes

Focused Correct Explanation: 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

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? a) "Client visibly agitated during assessment and unwilling to continue." b) "Client became upset and terminated assessment." c) "During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." d) "During chest auscultation, client decided that she could no longer participate in assessment and removed herself from the room."

"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." Explanation: Documentation should be as objective and precise as possible. Answers A and B attribute the client's behavior to being agitated and upset, both of which are terms lacking in precision and objectivity. Answer D is more objective, but answer C provides the most detailed, objective account of what transpired.

Which of the following data entries follows the recommended guidelines for documenting data? a) "Patient is overwhelmed by the diagnosis of pancreatic cancer." b) "Patient kidneys are producing sufficient amount of measured urine." c) "Following oxygen administration, vital signs returned to baseline." d) "Patient complained about the quality of the nursing care provided on previous shift."

"Following oxygen administration, vital signs returned to baseline." Explanation: The nurse should record patient 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 nurse who is new to the health clinic and who recently graduated from a nursing program tells a client at the end of an interview that data the nurse has just collected from the client needs to be validated. The client, an elderly gentleman, gives the nurse a strange look and says, "Validate my data? What does that mean?" How should the nurse respond to this client? a) "It means I need to make sure that all the information I gathered today is reliable and accurate." b) "It means I need to have the physician come in and look over your chart to make sure I didn't miss anything." c) "It means that I need you to sign a statement in which you confirm that everything you have shared with me today is true." d) "It means I need to take all of your vital signs one more time."

"It means I need to make sure that all the information I gathered today is reliable and accurate." Explanation: Validation of data is the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate. Validation does not mean that the nurse must retake all of the client's vital signs, have the physician check the patient's chart, or have the client sign a statement

Which of the following examples of documentation best exemplifies sound clinical documentation practices? a) "Client is anxious during questioning regarding health history and family history." b) "Abnormal chest sounds noted during posterior chest auscultation." c) "Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter." d) "Client reports sharp pain to chest on deep inspiration."

"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter." Explanation: 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

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 a) "the client's lung sounds were clear on both sides." b) "bilateral lung sounds clear." c) "after listening to client's lung sounds, both lungs appeared clear." d) "client's lung sounds were auscultated with stethoscope and were clear on both sides."

"bilateral lung sounds clear." Explanation: 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."

A nurse is explaining to a new client that the office uses electronic health records (EHRs) for all clients. The client says that at his last office, they used electronic medical records (EMRs). He asks whether these are the same thing. The nurse explains that they are different. Which of the following is a characteristic that is true of an EMR? a) A record designed to reach out beyond the health organization that originally obtains the data b) A record supplied by a physician in which diagnoses and prescribed treatments are recorded c) A record that is intended for sharing data with many different types of health care providers d) A record that covers the more comprehensive health status of the client

A record supplied by a physician in which diagnoses and prescribed treatments are recorded Explanation: The two terms electronic health records and electronic medical records are often used in place of each other. However, they represent two different forms of electronic documentation. The term EMR, which existed before the term EHR, referred to medical records supplied by physicians who made medical diagnoses and prescribed treatments. The more recent term EHR is more commonly used as it refers to the more comprehensive health status of the client, not just the medical status. Thus the EHR may be used by a variety of health care providers, not just physicians. EHRs focus on the total health (emotional, physical, social, spiritual) of the client and are designed to reach out beyond the health organization that originally obtains the client 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? a) Communicate face to face with good eye contact b) Ask the other nurse to read back what first nurse reported c) Provide documentation of the data you are sharing d) Have the other nurse speak with the attending physician to clear up any misunderstandings

Ask the other nurse to read back what first nurse reported Correct Explanation: 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.

A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding? a) Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. b) Client reports headache. c) Client has a dull, aching pain in the back of his head that began 2 weeks ago. The pain is constant and seems to be worse in the mornings. d) Client has severe headache, probably related to alcoholism.

Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. Explanation: As this is subjective data, the nurse should record it as the "client reports" instead of the "client has," to clarify that this is based on the client's perception. The nurse should use phrases instead of sentences for brevity. Finally, the nurse should record complete information and details for all client symptoms or experiences, not just, "Client reports headache."

Which assessment is most likely performed when a client is admitted to the hospital? a) Shift b) Focused c) Abbreviated d) Comprehensive

Comprehensive Explanation: A comprehensive assessment of the client is performed by a hospital nurse on admission. A shift assessment is performed at the beginning of each shift. A focused assessment is a very brief assessment of potential problems. An abbreviated assessment is a term not commonly used but is similar to a focused assessment.

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? a) Nursing minimum data set b) Open-ended forms c) Cued or checklist forms d) Integrated cued checklist

Cued or checklist forms Explanation: Cued or checklist forms promote easy and rapid documentation while categorizing information. Open-ended forms are the traditional forms that individualize information and allow the narrative description of problems. An integrated cued checklist combines assessment data with identified nursing diagnoses. A nursing minimum data set is usually a computerized document and is often used in long-term care facilities.

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? a) 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. b) Bruises and cuts to face and torso. Client appears to have been severely beaten by her husband. c) Bruises on chest and back with multiple cuts on her face. d) Multiple bruises and cuts on client's body. Client states she fell down a flight of stairs.

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. Explanation: Documentation needs to be clear and specific. Documentation should describe and provide a location of the areas. Documentation should also include any assumptions or judgements.

A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose? a) Subjective information is often missing b) It reflects poor assessment skills on the part of the nurse c) The charting format is not ethical d) Details are often missing

Details are often missing Explanation: CBE may pose legal problems, because details are often missing. CBE does not omit subjective assessment, CBE is an ethical form of charting, and the question does not indicate that the assessment skills of the nurse are lacking in any form

Why is accurate and effective documentation most important? a) It ensures that data can be used for research purposes. b) It can be used to educate other nurses. c) It keeps patients informed about their care. d) Documentation constitutes a legal record.

Documentation constitutes a legal record. Explanation: The patient record serves as a legal document recording the patient's health status and any care he or she receives. The patient record can be used in civil or criminal courts to provide evidence of wrongdoing.

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes? a) Evaluate nursing care provided b) Evidence in a situation of wrongdoing c) Reimbursement for care provided d) Discharge planning for the patient

Evidence in a situation of wrongdoing Explanation: 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 patients 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 patient discharge. Information in the patient's medical record is used to determine reimbursement by Medicare, Medicaid, workers' compensation insurance, and third-party insurance companies for care.

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? a) Shift level b) Patient level c) Department level d) Facility level

Facility level Explanation: Accrediting agencies such as The Joint Commission or state agencies such as departments of health can establish standards and audit patient records to evaluate the quality of care provided. The Joint Commission accreditation is often required for facilities to obtain Medicare and Medicaid funding, so hospitals are motivated to comply with the standards in documentation and care that The Joint Commission sets

When an agency has policies that require nurses to write focus notes, the nursing documentation can include what? a) Areas of personal accomplishments b) Social networks c) Family concerns d) Areas of personal weakness

Family concerns Explanation: Documentation can focus on areas of strengths as well as medical problems, family concerns, or nursing diagnoses. Focus notes do not generally include areas of personal accomplishments, personal weaknesses, or the client's social networks

The nurse is reviewing the patient's medical record. Which does the nurse recognize as accurate documentation? a) Patient is confused and combative. b) Patient is overweight. c) Patient's pain is tolerable. d) Hyperactive bowel sounds are heard in all four quadrants.

Hyperactive bowel sounds are heard in all four quadrants. Explanation: Accurate documentation is detailed and explicit. The nurse would recognize bowel sounds are hyperactive in all four quadrants as accurate documentation. The three remaining options are judgment without specific supporting information. The patient's weight and pain rating should be specified. Specific comments and behaviors should be documented to support the judgment of confusion and combativeness

When using the SBAR communication tool to inform the physician of a client's high blood pressure and anxiety, the nurse should make which statement first while on the phone with the physician? a) "Your client has a high blood pressure and takes antihypertensives at home." b) "You need to come assess this client at the bedside." c) "I am a registered nurse caring for your client." d) "The client's blood pressure is 180/85, pulse is 94 and client appears anxious."

I am a registered nurse caring for your client." Explanation: The S in SBAR stands for situation. The nurse should first identify his/her self, then provide background information, followed by assessment data, and the nurse's recommendation. The other information in the answer options is relevant and should be relayed to the physician; but the first action is to identify self.

When charting by exception is used in a health care agency, the most important aspect of this method is what? a) Identifying the standards and norms for the institution b) Organizing new forms for the nursing staff c) Training new nurses in writing charting by exception notes d) Pulling together a group of experts to teach agency staff

Identifying the standards and norms for the institution Explanation: Clearly identifying the standards and norms and educating all users takes time and significant commitment from the agency using charting by exception. Organizing new forms for the nursing staff, training new nurses, and acquiring teachers for agency staff may be important, but they are not the most important aspect of this method.

A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse? a) It disables the graphing of trends in vital signs or assessment data. b) It automatically corrects both spelling and grammar. c) It maximizes compliance with standards of documentation. d) It allows several health team members to view the patient record simultaneously.

It allows several health team members to view the patient record simultaneously. Explanation: Electronic medical records allow several health care team members to view the patient record simultaneously.

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? a) It provides quick access to abnormal findings. b) It records progress under problems, interventions, and evaluation. c) It provides and refers to client's problem by a number. d) It documents assessments on separate forms.

It provides quick access to abnormal findings. Explanation: Charting by exception provides quick access to abnormal findings as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

Examples of objective data include all the following except: a) Coughing b) Itchy skin c) Reddened skin d) Foul-smelling discharge

Itchy skin Explanation: 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

The nurse enters a client's room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse's best action? a) Scan the barcode on the client's chart, then administer the medications. b) Ask the client for name and birth date, then administer the medications. c) Confirm the client's identity with visitors who are present. d) Leave the room to obtain another armband for the client.

Leave the room to obtain another armband for the client. Explanation: The nurse should obtain another armband for the client; that's the safest action. Confirming identity with visitors does not meet national client safety standards. Just asking the client for name and birth date means that the barcode system is bypassed; this is not necessary. The medications are scheduled, not emergent, so the nurse has time to get another armband and avoid a barcode override. Scanning the barcode on a chart does not ensure the client in the room is the right client. Another client could have wandered into this client's room

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

Limiting abbreviations to those approved for use by the institution. Explanation: 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 patient's potential understanding of abbreviations is not taken into account during the process of documentation.

Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015? a) Evidence of validation of all vital sign measurements b) Data backup of all digital files c) Use of a standard method of data communication d) Meaningful use of electronic health records

Meaningful use of electronic health records Explanation: Since the Health Information Technology for Economic and Clinical Health Act of 2009 was adopted, there has been a slow but steady increase in use of EHRs by health care agencies and primary health care providers. To encourage the use of EHRs, Medicare and Medicaid began to offer federal incentive payments of $2 million or more to health care providers and hospitals to use EHR technologies. In addition, penalties will be applied to providers unable to demonstrate meaningful use of EHRs by 2015.

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record patient conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? a) Narrative notes b) Charting by exception c) SOAP notes d) Focus charting

Narrative notes Explanation: 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

Which assessment form provides a nurse with the ability to compare nursing data across clinical populations, settings, geographical areas, & time? a) Integrated cued checklist b) Open-ended forms c) Cued or checklist forms d) Nursing minimum data set

Nursing minimum data set Correct Explanation: The nursing minimum data set establishes comparability of nursing data across clinical populations, settings, geographic areas, and time. Open-ended forms, cued or checklist forms, and integrated cued checklists do not provide such comparability of nursing data

Which assessment form is appropriate for a nurse to use when performing an initial assessment for a client? a) Nursing minimum data set b) Frequent vital signs sheet c) Cardiovascular assessment sheet d) Assessment flow chart

Nursing minimum data set Explanation: When performing the initial assessment for a client the nurse should use the nursing minimum data set form, which covers all aspects of the complete client assessment. Frequent vital signs sheet and assessment flow charts are ongoing assessment forms. A frequent vital signs sheet is used to record vital signs in a graphic format for easy visualization of abnormalities. The assessment flow chart allows for rapid documentation and comparison of recorded assessment data from one time period to the next. A cardiovascular assessment sheet is used to focus only on the cardiovascular problem areas; this is a focused or specialty area assessment form.

What is the nurse's best defense if a patient alleges nursing negligence? a) Testimony of other nurses b) Testimony of expert witnesses c) Patient's record d) Patient's family

Patient's record Explanation: The patient record is the only permanent legal document that details the nurse's interactions with the patient. It is the best defense if a patient or patient surrogate alleges nursing negligence

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? a) Problem list b) Plan of care c) Data base d) Progress notes

Progress notes Explanation: 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 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? a) Plan of care b) Clinical pathway c) Flow sheets d) Progress notes

Progress notes Explanation: Multiple members of the health care team document in a progress note the patient's progress toward recovery. The plan of care details individualized goals, outcomes, and interventions for the patient, while a critical pathway is a multidisciplinary tool that identifies a standard plan of care for a specific patient population. Flow sheets are used to document routine, scheduled nursing assessments and assist in the analysis of trends in patient data

A patient with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the patient's chart. The nurse knows to look at what part of the patient's medical record to check the current medical diagnosis? a) Progress notes b) Admission history c) Medication record d) Demographic data sheet

Progress notes Explanation: All members of the healthcare team use the progress notes to record the patient's progress and any changes. The demographic sheet contains the patient's personal information. The admission history states the problems upon admission. The medication record lists all medications that the patient has been and are scheduled to be given

The nurse identifies the UAP recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse? a) Notify the physician b) Recheck blood pressure in 30 minutes c) Have the UAP retake the blood pressure d) Reassess blood pressure

Reassess blood pressure Correct Explanation: 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 patient's condition. The nurse should retake the blood pressure immediately as it is abnormally low for this patient. 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

The nurse manager at an extended care facility is incorporating bar code scanners into client care. Bar code scanners have been utilized in client care to address which issue of quality hospital care? a) Cost of care b) Reduction in medical error c) Evidence-based medicine d) Medical ethics

Reduction in medical error Explanation: The main issues in quality hospital care include evidence-based medicine, quality assurance, medical ethics, and the reduction in medical error. Bar code scanners are utilized to decreased the risk of a medication administration error

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? a) Asking the physician to come in and take the client's blood pressure b) Repeating the measurement with a different sphygmomanometer and stethoscope c) Asking the client whether his diet has changed in the past year d) Asking the client whether his exercise habits have changed recently

Repeating the measurement with a different sphygmomanometer and stethoscope Explanation: 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? a) DAR b) SOAP c) PIE d) SBAR

SBAR Explanation: 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.

A nursing instructor is teaching how to document vital signs on the chart. The student demonstrates understanding of accurate documentation when she makes the following recording in the chart: a) Vitals are normal. b) Vitals are within normal limits. c) Vitals remain stable. d) T 37C, P 80, R 12 breaths/min, BP 118/62 mm Hg.

T 37C, P 80, R 12 breaths/min, BP 118/62 mm Hg. Correct Explanation: When documenting on the chart, the nurse must avoid using words like "normal" or "good" and instead use correct medical terminology. Documentation must be concise and precise. Accuracy permits comparison of current findings with future data to detect changes in patient status.

A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered? a) The presence of a lump in the client's breast discovered on palpation b) A 24-hour recall of what the client has eaten c) The client's weight d) A description of gall bladder surgery the client had 10 years ago e) 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 • A description of a large bruise on the client's thigh Explanation: 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.

To make a legal entry into the medical record, the nurse must document what? a) Nature of the assessment b) Time of the assessment c) Laboratory tests ordered d) Attending physician

Time of the assessment Explanation: The nurse must record normal assessment data, abnormal assessment data, and the time of the assessment. The nurse does not have to document laboratory tests ordered, the attending physician, or the nature of the assessment

A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer? a) To be able to verify what care has been given b) To have up-to-date information on which to base clinical decisions c) To communicate with other health care providers d) To be able to update the plan of care

To have up-to-date information on which to base clinical decisions Explanation: All the responses are correct; however, the best answer is that prompt documentation allows health team members to use up-to-date assessment information to make clinical decisions.

A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance? a) To provide a record of the actual events b) To provide a record of how the client was harmed c) To provide a record of the physician's activities d) To provide a record of the nurse's activities

To provide a record of the actual events Explanation: The client record serves as a legal document recording the client's health status and any care the client receives. While all answers are correct, the best answer is providing a record of the actual events.

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? a) Use an eraser to remove any error in the document. b) Use phrases instead of sentences to record data. c) Record "normal" for all normal findings if required. d) Record how data findings were obtained.

Use phrases instead of sentences to record data. Explanation: The nurse should document assessments using phrases instead of sentences to avoid the use of too many redundant words and to focus only on the essential (information) terms. Errors in documentation should be corrected by drawing one line through the entry, writing "error," and initialing the entry; an eraser should not be used to remove any error in the document. A pencil or pen with erasable ink should never be used in documentation. The nurse needs to record only the data findings, not how the data findings were obtained, in precise terms. All findings should be recorded as per the values obtained during assessment in descriptive terms, even if the finding is normal

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case? a) Verify the data by having another nurse come in to perform the percussion. b) Confirm that the client has truly never been a smoker by asking him. c) Repeat the percussion using the nondominant hand. d) Clarify the data by asking whether the client has experienced any trouble breathing lately

Verify the data by having another nurse come in to perform the percussion. Explanation: The most appropriate method of validation in this case would be to have another nurse come in to perform the percussion. We know that the nurse is inexperienced, and with all of the other information supplied, it is much more likely that the discrepancy is due to improper percussion technique or faulty interpretation of the sound than it is to the client actually having emphysema. Repeating the procedure with the nondominant hand is not likely to change the results. If the client appears healthy and has not reported breathing difficulty, it is not likely that he has emphysema. If the client has already denied smoking, asking him again will likely only insult him.

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? a) Failure to identify an record patient problems and associated interventions. b) Vulnerability to legal liability since the nurse's safe, routine care is not recorded. c) Significant differences in charting between nurses due to lack of standardization. d) Increased workload for nurses in order to complete necessary documentation.

Vulnerability to legal liability since the nurse's safe, routine care is not recorded. Correct Explanation: A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation and both standardization of charting and identification of patient-specific problems are possible within this documentation framework

A nurse is caring for a patient 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: a) charting by exception b) narrative charting c) batch charting d) pie charting

charting by exception Explanation: Charting by exception uses predetermined standards and norms to record only significant assessment data, and only abnormal findings require additional documentation. Narrative charting is done using unstructured paragraphs to record assessments and other activities. Pie charting includes stating the problem, interventions, and evaluation. Batch charting is waiting until the end of shift or after all patients have been assessed to chart

If the nurse makes an error while documenting findings on a client's record, the nurse should a) erase the error and make the correction. b) obliterate the error and make the correction. c) draw a line through the error and have it witnessed. d) draw a line through the error, writing "error" and initialing.

draw a line through the error, writing "error" and initialing. Explanation: 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.

An assessment form commonly used in long-term care facilities is the nursing minimum data set. One primary advantage to this type of assessment form is that it a) establishes comparability of nursing data across clinical populations. b) allows for individualization for each client in the health care setting. c) clusters all the nursing and medical diagnoses in one place. d) uses a flowchart format for easy documentation of objective data.

establishes comparability of nursing data across clinical populations. Explanation: Nursing minimum data set establishes comparability of nursing data across clinical populations, settings, geographic areas, and time.

An assessment form commonly used in long-term care facilities is the nursing minimum data set. One primary advantage to this type of assessment form is that it a) clusters all the nursing and medical diagnoses in one place. b) allows for individualization for each client in the health care setting. c) establishes comparability of nursing data across clinical populations. d) uses a flowchart format for easy documentation of objective data.

establishes comparability of nursing data across clinical populations. Explanation: Nursing minimum data set establishes comparability of nursing data across clinical populations, settings, geographic areas, and time.

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 a) progressive. b) specific. c) checklist. d) focused.

focused. Explanation: Some institutions may use assessment forms that are focused on one major area of the body for clients who have a particular problem. These forms are usually abbreviated versions of admission data sheets, with specific assessment data related to the purpose of the assessment

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should a) validate all data before documentation of the data. b) use medical terms that are commonly used in health care settings. c) document the data after the entire examination process. d) record the nurse's understanding of the client's problem.

validate all data before documentation of the data. Explanation: Validation of data verifies the assessment data that you have gathered from the client. It consists of determining which data require validation, implementing techniques to validate, and identifying areas that require further assessment data

A legal nurse consultant explains to a group of nursing students that the medial record serves what purpose? Select all that apply. a) Determining eligibility for reimbursement b) Promoting effective communication between caregivers c) Providing client education d) A method to gather research data e) Legal document of care

• Determining eligibility for reimbursement • Legal document of care • A method to gather research data • Promoting effective communication between caregivers Explanation: The medical record serves as a legal document, promotes communication between caregivers, data for research, eligibility for reimbursement and education for health care students. It does not provide client education

Which strategy reduces documentation errors? Select all that apply. a) Designate a person to document during emergencies. b) Organize patient data logically, using a timed sequence. c) Document patient information after assessing all assigned patients. d) Document patient information immediately. e) Document ambiguous patient information. f) Document ambiguous patient information.

• Document patient information immediately. • Designate a person to document during emergencies. • Document ambiguous patient information. • Organize patient data logically, using a timed sequence. Explanation: Strategies that reduce documentation error include documenting patient information immediately, organizing patient 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 patients

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): a) organized b) timely c) biased d) complete e) accurate f) concise

• organized • accurate • timely • concise • complete Correct Explanation: Quality assessment data remain confidential, accurate, concise, complete, organized, and timely. Findings are not biased but factual.