Documentation

The nurse works at an agency where military time is used for documentation, and needs to document that a patient was transported to the operating room for an emergency procedure at 8 in the evening. Point to the area on the clockface below that indicates 8 in the evening in military time: Clock shows timings from 1300 to 2400 in increments of 100.

2000

The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O): a. April 24, 2019 (0900) b. Repositioned patient on left side. c. Medicated with hydrocodone-acetaminophen 5/325 mg, 2 tablets PO. d. "The pain in my incision increases every time I try to turn on my right side." e. S. Eastman, RN f. Surgical incision right lower quadrant, 3 inches in length, well approximated, sutures intact, no drainage g. Rates pain 7/10 at location of surgical incision.

O:a,b,c,e,f,g S:d

Match each line of documentation with the appropriate SOAP category (Subjective [S], Objective [O], Assessment [A], Plan [P]). a. _ Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. b. _ "The pain increases every time I try to turn on my left side." c. _ Acute pain related to tissue injury from surgical incision. d. _ Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.

S-b O-d A-c P-a

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? a. "CPOE reduces transcription errors." b. "CPOE reduces the time needed for health care providers to write orders." c. "CPOE eliminates verbal and telephone orders from health care providers." d. "CPOE reduces the time nurses use to communicate with health care providers."

a

A nurse has finished getting shift report. Which patient should the nurse see first? a. Patient just transferred from the emergency department b. Patient who needs to get out of bed and ambulate c. Pneumonia patient getting respiratory treatment d. Postoperative patient requesting pain medication

a

A nursing student is confused and frustrated working with NIC/NOC/NANDA language on care plans. What advantage of this system does the nursing faculty explain to the student? a. It is a common language that can be incorporated into clinical information systems. b. It is easy-to-implement nursing-focused language that all systems will eventually use. c. It provides an avenue for understandable billing practices for health care costs. d. Its specific nomenclature and wording increase the visibility of nursing as a profession.

a

The nurse is working the evening shift at a hospital that uses military time for documentation. The nurse administered morphine 2 mg intravenously (IV) for pain at 3:45 PM, changed the dressing over the patient's abdominal incision at 5:34 PM, and administered Ancef 1 g IV at 8:00 PM. Using correct military time, which of the following is the correct label of documentation for each task with the time that it was completed? a. 15 45, 17 34, 20 00 b. 3 45, 17 34, 20 00 c. 15 45, 5 34, 8 00 d. 3 45, 5 34, 8 00

a

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to sever pain. Which of the following nursing actions are appropriate? (Select all that apply.) a. Repeat the details of the prescription back to the provider b. Have another nurse listen to the telephone prescription c. Obtain the providers signature on the prescription within 24 hr. d. Decline the verbal prescription because it is not an emergency situation Tell the charge nurse that the provider has prescribed morphine by telephone

a,b,c

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply.) a. Medication error b. Needlesticks c. Conflict with provider and nursing staff d. Omission of prescription e. Missed specimen collection of a prescribed laboratory test

a,b,d

A nurse is reviewing health care-related information on the Internet using the CARS acronym. Which of the following are components of this system? (Select all that apply.) a. Accuracy b. Credibility c. Rationale d. Reasonableness e. Support

a,b,d,e

While reviewing the pulmonary assessment entered by a nurse in a patient's electronic medical record (EMR), a physician notices that the only information documented in that section is "WDL" (within defined limits). The physician also is not able to find a narrative description of the patient's respiratory status in the nurse's progress notes. What is the most likely reason for this? a. The nurse caring for the patient forgot to document on the pulmonary system. b. The EMR uses a charting-by-exception format. c. The computer shut down unexpectedly when the nurse was documenting the assessment. d. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment.

b

The nurse is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a registered nurse (RN) who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of information does the nurse include in the documentation of this telephone call? (Select all that apply.) a. The patient's name, age, and admitting diagnoses b. The discussion of any allergies to food and medications that the patient has c. That the nurse receiving the report was advised that the patient is "needy" and "on the call light all the time" d. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol e. Description of any unresolved problems and current interventions in place

a,b,d,e

The nurse who works at the local hospital is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient's electronic health record must be printed and faxed to the acute rehabilitation center. Which of the following actions is most appropriate for the nurse to take to maintain privacy and confidentiality of the patient's information when faxing this information? (Select all that apply.) a. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. b. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. c. Fax the patient's information without a cover sheet so that the person receiving the information at the acute rehabilitation center can identify it more quickly. d. After sending the fax, place the information that was printed out in a standard trash can after ripping it into several pieces. e. After sending the fax, place the information that was printed out in a secure canister marked for shredding.

a,b,e

The nurse is working in an agency that has recently implemented an electronic health record. Which of the following are acceptable practices for maintaining the security and confidentiality of electronic health record information? (Select all that apply.) a. Using a strong password and changing your password frequently according to agency policy b. Allowing a temporary staff member to use your computer user name and password to access the electronic record c. Ensuring that work lists (and any other data that must be printed from the electronic health record) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed d. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care e. Remaining logged in to a computer to save time if you only need to step away to administer a medication

a,c,d

The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student: (Select all that apply.) a. Documents a medication given by another nursing student. b. Includes the date and time of the entry into the medical record. c. Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient's room. d. Leaves a slip of paper with her user name and password in the patient's room. e. Starts to enter "Docusate sodium 100 mg ordered at 08:00 held. Patient declined to take dose stating, "I had several loose stools yesterday, and I'm afraid if I take this dose the problem will get worse," as a narrative comment.

a,d

A nurse and health care provider are talking in the hallway about a patient's condition. The health care provider says that the patient needs an x-ray. Which action by the nurse is most appropriate? a. Document the order and facilitate the patient having the x-ray. b. Explain that you will call x-ray when the health care provider inputs the order. c. Inform the health care provider that verbal orders are prohibited now. d. Repeat the order to the health care provider and document it in the chart.

b

A patient states, "I would like to see what is written in my medical record." What is the nurse's best response? a. "Only your family can read your medical record." b. "You have the right to read your record." c. "Patients are not allowed to read their records." d. "Only health care workers have access to patient records."

b

The nurse contacts a provider about a change in a patient's condition and receives several new orders for the patient over the phone. When documenting telephone orders in the electronic health record, most hospitals require a nurse to do which of the following? a. Print out a copy of all telephone orders entered into the electronic health record in order to keep them in personal records for legal purposes. b. "Read back" all telephone orders to the provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the electronic health record. c. Record telephone orders in the electronic health record, but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. d. Implement telephone order(s) immediately, but insist that the health care provider come to the patient care unit to personally enter the order(s) into the electronic health record within the next 24 hours.

b

Which requirement for technologically enhanced prescribing does Medicare Part D require? a. Automatic conversion from brand to generic drugs b. Drug plans must support electronic prescribing c. Online, 24-hour Internet pharmacist support d. Physician entry order systems in the hospital

b

A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) a. Cover errors with correction fluid and write in the correct information b. Put the date and time on all entries c. Document objective data, leaving out opinions d. Use as many abbreviations as possible e. Wait until the end of shift to document

b,c

An nurse is discussing the HIPAA Privacy Rule with nurses during new employee orientation. Which of the following info should the nurse include? (select all) A. A single electronic records password is provided for nurses on the same unit B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurse's station D. A client can request a copy of her medical record E. A nurse my photocopy a client's medical record for transfer to another facility.

b,c,d,e

A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? a. Input and output for the shift b. Blood pressure from the previous day c. Bone scan scheduled for today d. Medication routine from the medication administration record

c

A nurse is writing a telephone order for medication. Which written order is the safest? a. Furosemide (Lasix) 10.0 mg b.i.d. b. Furosemide (Lasix) 10 mg bid PO c. Furosemide (Lasix) 10 mg two times a day orally d. Furosemide (Lasix) 10 mg 2×/day by mouth

c

A preceptor observes a new graduate nurse discussing changes in a patient's condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse: a. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone. b. Documents the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record. c. Gives a newly ordered medication before entering the order in the patient's medical record. d. Asks the preceptor to listen in on the phone conversation.

c

A staff nurse is interested in informatics and wishes to become an Informatics Nurse Specialist (INS). What step is necessary to obtain that certification? a. Earn a bachelor's degree in computer science or informatics. b. Get on-the-job training in software from a software vendor. c. Obtain graduate education in informatics or a related specialty. d. Take the certification exam offered by the National League of Nursing.

c

An experienced nurse is precepting a new graduate. Prior to charting, the preceptor instructs the new nurse to do which of the following? a. Abbreviate as much as possible to keep records short. b. Do not use any abbreviations at all in patients' charts. c. Look up the facility's list of "do not use" abbreviations. d. Use only abbreviations seen in other nurses' charting.

c

The nurse is administering a dose of metoprolol to a patient, and is completing the steps of bar code medication administration within the EHR. As the bar code information on the medication is scanned, an alert that states "Do not administer dose if apical heart rate (HR) is <60 beats/minute or systolic blood pressure (SBP) is <90 mm Hg" appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system? a. Electronic health record (EHR) b. Charting by exception c. Clinical decision support system (CDSS) d. Computerized physician order entry (CPOE)

c

The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system? a. Electronic health record b. Clinical documentation c. Clinical decision support system d. Computerized physician order entry

c

The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response? a. HIPAA allows all hospital staff access to your medical record. b. HIPAA limits the information that is documented in your medical record. c. HIPAA provides you with greater protection of your personal health information. d. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

c

What is the appropriate way for a nurse to dispose of information printed out from a patient's electronic health record? a. Rip the papers up into small pieces and place the pieces into a standard trash can b. Place all papers in the flip-top binder designated for that patient that is located in the nurse's station on the patient care unit c. Place papers with patient information in a secure canister marked for shredding d. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit

c

When documenting an assessment of a patient's cardiac system in an electronic health record, the nurse uses the computer mouse to select the "WNL" statement to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80-100 beats per minute, and regular. Denies chest pain." This is an example of using which of the following documentation formats? a. Focus charting incorporating "Data, Action & Response" (DAR) b. Problem-intervention-evaluation (PIE) c. Charting-by-exception (CBE) d. Narrative documentation

c

A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information? a. "Avoid rushing when documenting an entry in the medical record." b. "Use correction fluid to remove the entry." c. "Draw a single line through the statement and initial it." d. Enter only objective and factual information about a patient in the medical record.

d

A nurse is administering medications using bar code technology. One of the medications does not have a full bar code on it. Which action by the nurse is best? a. Bypass the bar code system and give the drug. b. Fill out a variance report and administer the drug. c. Have a second nurse verify the drug information. d. Obtain a new dose; return the old one to the pharmacy.

d

A nurse is preparing to discharge a patient who speaks very little English. Which action by the nurse is best? a. Print the instructions in the patient's native language. b. See if a family member can interpret the instructions. c. Teach a family member the discharge instructions. d. Use a professional interpreter to give the instructions.

d

As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this observation of the patient? a. "The patient has a defiant attitude and is demanding test results." b. "The patient appears to be upset with the nurse because he wants his test results immediately." c. "The patient is demanding and is complaining about the doctor." d. "The patient stated feelings of frustration from the lack of information received regarding test results."

d

The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon (Dr. Oakman) by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation? a. Health care provider notified about change in assessment of abdominal incision. T. Wright, RN b. 09-3-18: Notified Dr. Oakman by phone that there is a new area of redness around the patient's incision. T. Wright, RN c. 1015: Contacted Dr. Oakman and notified about changes in abdominal incision. T. Wright, RN d. 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN

d

The nurse is discussing the advantages of using computerized provider order entry (CPOE) with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an electronic health record? a. CPOE reduces the time necessary for health care providers to write orders. b. CPOE reduces the time needed for nurses to communicate with health care providers. c. Nurses do not need to acknowledge orders entered by CPOE in an electronic health record. d. CPOE improves patient safety by reducing transcription errors.

d

The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contain an inappropriate abbreviation included on The Joint Commission's "Do Not Use" list and should be clarified with the health care provider? a. Change open midline abdominal incision daily using wet-to-moist normal saline and gauze. b. Lorazepam 0.5 mg PO every 4 hours prn anxiety c. Morphine sulfate 1 mg IVP every 2 hours prn severe pain d. Insulin aspart 8u SQ every morning before breakfast

d

Which of the following documentation entries is most accurate? a. "Patient walked up and down hallway with assistance, tolerated well." b. "Patient up, out of bed, walked down hallway and back to room, tolerated well." c. "Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk." d. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."

d