Documentation

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?

Subjective data should be included when documenting.

A nurse has a two-way video communication with the specialist involved in the care of a patient in a long-term care facility. This is an example of what nursing informatics technology?

Telemedicine and mobile technology

A nurse is giving a verbal report to a physician using the ISBAR communication technique regarding a client with signs and symptoms of fluid volume deficit. Which statements should the nurse include in the report?

"I am the nurse assigned to the client." • "The client has been complaining about dizziness when walking." • "The client vomited twice and has dry mucous membranes." • "Current blood pressure is 90/50 mmHg with a pulse of 112 BPM." • "I encourage the client to take sips of fluid after giving the ordered antiemetic."

Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his physician wrote in his chart. Among the provisions of HIPAA are clients' rights to see and read their medical records. Negotiation with an insurance provider, the necessity of a second opinion, and out-of-state care are aspects of care that fall within the specific auspices of HIPAA

Which documentation tool will the nurse use to record the patient's vital signs every 4 hours?

A graphic sheet is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.

A nurse is requesting to receive change of shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving report at the bedside. Which response by the nurse receiving report is most appropriate?

It will allow for us to see the client and possibly increase client participation. We want the client to participate in their care. While we can see what is done, that isn't the main reason for bedside reporting. IT SHOULD BE CLIENT FOCUSED.

Besides being an instrument of continuous client care, the client's medical record also serves as a(an)

Legal document The client record serves as a legal document of the client's health status and care received.

Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing?

Nutritional consult.

A nurse is preparing a seminar on the uses of documentation in client records. Which topics should the nurse include in the seminar?

Quality improvement • Research • Decision Analysis • Financial reimbursement

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. What statement by the nurse is most accurate?

The benefit of CBE is less time needed on computer charting.

According to the American Nurses Association (ANA), what is the primary source of evidence to measure performance outcomes against standards of care?

documentation

A patient accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?

Accurately documenting patient care on the patient record! that is the only good defense for a patient saying that the nurse has wronged them.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member. ASKING OTHERS FOR INFO VIOLATES CLIENT PRIVACY.

A nurse documents the following patient data in the patient record according to the SOAP format: Patient complains of unrelieved pain; patient is seen clutching his side and grimacing; patient pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

Problem-oriented method Explanation: The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of patient problems and contributes collaboratively to the plan of care. Progress notes clearly focus on client problems. Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically. PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). Focus charting method brings the focus of care back to the client and the client's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a client and client care. (less)

A nurse manager of a physician's office is responsible for obtaining signed authorizations for releasing patient information to third parties. In which situations would the nurse not need an authorization from the patient

• Reporting the incidence of an infectious disease to Center for Disease Control • Releasing a medical record to the court when a nurse is being sued for negligence • Facilitating organ donation of a deceased patient • Providing statistics related to the use of a dangerous piece of equipment