Documentation and Interprofessional Communication
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
What is the name of the information program mandated by the federal government for the initial and ongoing assessment of Medicare and Medicaid clients in the homecare setting?
OASIS
The nurse is documenting client care. Which nursing assessment note would be appropriate?
"Client voices concerns about being able to change abdominal dressings at home."
During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?
"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."
The nurse prepares to document information collected during an assessment. Which statement correctly documents subjective data?
"I have pain across my entire forehead."
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?
"It means I need to make sure that all the information I gathered today is reliable and accurate."
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
A nurse is working in a health care facility that is using charting by exception. Which of the following would the nurse expect to document?
Aching, burning pain in lower back
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
The nurse maintains confidentiality when working with clients and demonstrates an understanding of the Health Insurance Portability and Accountability Act (HIPAA) by doing the following:
Communicating information about the client to other health team members
Why is accurate and effective documentation most important?
Documentation constitutes a legal record.
A nurse makes an incorrect entry onto a client's paper record during documentation of the assessment data. What is the correct way for the nurse to fix this error?
Draw a line through the error, write "error", and initial the entry
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
The nurse is reviewing the client's medical record. Which does the nurse recognize as accurate documentation?
Hyperactive bowel sounds are heard in all four quadrants.
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.
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.
Computerized charting is expensive but also has many benefits. One such benefit is:
It improves legibility.
A computerized risk assessment report correlates data and provides scores on various aspects of clients in the health care facility. Why would this be beneficial for client care?
Notifies health care providers when clients show clinical signs of deterioration
A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Repeating the measurement with a different sphygmomanometer and stethoscope
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?
SBAR
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
A nurse is caring for a client recovering from surgery 6 hours ago. The client's urinary output has been less than 100 since return to the floor. The nurse notifies the surgeon. When documenting the phone call to the surgeon, the nurse must include which of the following? (Select all that apply.)
The call The time of the call Who was called Information given to the provider Information the nurse received
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
A nurse is having a new client complete a health history form and sign a form acknowledging his rights under the Health Insurance Portability and Accountability Act (HIPAA). The client asks the nurse what HIPAA covers. Which of the following most accurately describes what HIPAA covers?
The confidentiality of electronic and printed health information
A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?
The laboratory assistant can only retrieve medical records but cannot view the details.
Which example may illustrate a breach of confidentiality and security of client information?
The nurse provides information over the phone to the client's family member who lives in a neighboring state
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
A client who had a mastectomy is being discharged home on postoperative day 1. Knowing that the client lives alone, which data would be most important for the nurse to validate for this client?
What support systems are in place to assist the client
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:
have the right to copy their health records
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use?
an assessment flow chart
A nurse is caring for a client who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called:
charting by exception
While the nurse performs the initial assessment, the client states "This is my first hospitalization and I have had no previous surgeries." How would the nurse document this information?
client denies prior hospitalization and surgeries
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
In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed
focused
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
A nursing student is working a 7 a.m. to 3 p.m. shift with a preceptor and is caring for three clients independently. When the preceptor asks if the student has completed charting all her assessments, the student informs the preceptor that she is going to do batch charting. The preceptor informs the student of which of the following about batch charting?
it contributes to many potential errors
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
it provides quick access to abnormal findings
Examples of objective data include all the following except:
itchy skin
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
When performing an assessment, which of the following would be most helpful in validating a client's chief complaint?
objective data
A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?
progress note
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?
pt complaining of abdominal pain 8/10
A nurse organizes client data using the SOAP format. Which of the following would be recorded under "S" of this acronym?
pt complains of pain
A client's pain has become increasingly severe, but the client has received the maximum doses of analgesics. The nurse is receiving a new analgesic order from the health care provider. How would the nurse best validate the new order?
read the order back to the provider for confirmation
Mistakes in charting can be costly to both the client and nurse. The Joint Commission has listed a primary cause for these mistakes as a failure in communication. Life-threatening errors in health care have been labeled as which of the following:
sentinel events
A nurse has completed an assessment of a client with cholecystitis and is about to document the findings. Which statement best reflects accurate documentation?
skin pale, warm, and dry without evidence of lesions
A novice nurse is preparing for a physical examination of a client with neurological issues. The nurse takes a copy of the practice's standard assessment form and heads to the examination room, where the client is already waiting. A senior nurse notes the novice nurse's actions and says, "Here, use this form instead; it's an assessment form specifically for the neurological system." This second form is an example of which type of form?
specialty area assessment form
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
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 and objective data
The nurse is preparing to leave the unit for lunch. What type of communication method should the nurse use?
verbal handoff
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):
timely accurate complete organized concise
