Documentation study set

A health care facility plants to evaluate and revise the plan of care for a client based on the clients health care records. The physician, dietitian, and nurse involved in the clients care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the clients details? A) SOAP B)PIE charting C) narrative charting D) focus charting

A(in SOAP charting, everyone involved in a clients care makes entries in the same location in the chart)

In which step of the nursing process do you document all that you did for the client? A. Assessment B. Nursing diagnosis C. Planning D. Implantation E. Evaluation

D (it is important to document ALL the details of care because in the legal system, undocumented care means that it wAs not done! )

What are the major disadvantages of the narrative documentation. A. Difficult to record in chronological order B. Inflexible you client situations C. Saves time D. Wordiness

D (the major disadvantage of narrative documentation are wordiness and it is time consuming)

What is one of the most common complaints about written documentation? A. No signature B. Failing to record nursing actions C. Recording on incorrect record D. Illegible or messy handwriting

D( it is preferable to print your client notes if you have poor handwriting. Ask your colleagues if they can read your writing)

When describing wounds or lacerations, and if you don't have a ruler, use your thumb nail width as the unit of measurement. True or false?

False

Clients who are competent have the right to change their agent identified on the personal directives at any time. True or false.

True

When reporting a change in a clients condition in the progressive notes to a supervisor or physician, which of the following is inappropriate? A. Describe negative actions of the person you reported to B. Identify the individual by name and designation C. State what follow up was expected D. Identify and new orders or no orders

A (document only the facts. If you are not getting an appropriate response, activate the chain of command or fill out a professional responsibility form)

Which of the following is most likely to create an undesirable impression of the person doing clients documentation? A. Misspelled words and poor grammar B. Inappropriate abbreviations C. Messy handwriting D. Fancy signatures

A (others who read documentation with misspelled words or poor grammar may think or believe that the care provider who wrote the notes was uneducated or careless)

The majority of documentation framework are those of A. Exclusion B. Inclusion C. Narrative D. Charting by exception (CBE)

B (most documentation systems are inclusive, ie., data is recorded that describes both expected and unexpected outcomes)

At what step of the nursing process does the care provider document the clients health problems? A. Assessment B. Nursing diagnosis C. Planning D. Implementation E. Evaluation

B (the clients health problems relate to the standard of care required for each problem and is documented in the nursing care plan)

Which of the following would the legal system view as care "not done" A. Failing to record pertinent health or medication information B. Failing to record nursing actions

B (the legal system views undocumented care as "not done"

Which documentation method is problem oriented, includes the nursing process and that many interdisciplinary health teams use? A. DAR B. SOAP C. AIR D. POMR

B. (SOAP subjective, objective, assessment, plan)

In which step of the nursing process would you NOT normally chart or document? A. Assessment B. Nursing diagnosis C. Planning D. Implementation E. Evaluation

C ( you normally would not chart or document during the planning step, but you could make brief paper notes)

Which of the following is most likely to require special precautions and extra attention to detail? A. discontinued medication or treatment B. Medication reactions C. Telephone orders D. Medication administration

C (transcribing orders incorrectly or transcribing inaccurate orders are problematic. Numbers and dosages must be repeated back to the health professional issuing client orders)

During which step of the nursing process would you record direct quotes from the client and/or his family. A. Planning B. Nudging diagnosis C. Assessment D. Implementation

C (when doing assessment, it is useful to use direct quotes as this minimizes your opinions of the client)

Which of the following is an inaccurate descriptive phrase? A. Awake and resting in bed B. Awake, resting with no complaints of pain C. No complains of pain D. Tolerated procedure well

D ( this is a meaningless statement as it does not give any indication that a client Assessment was done)

If a client consistently refuses a medication, it is sufficient to record this in the progress notes. True or false.

False ( you should also record the reason why (if known) and what you did about the situation)

It is important that you document relevant complaints from staff, poor care and accusations in the clients record. True or false?

False (Keep documentation strictly client focused)

Only significant or major reactions to medications should be recorded. True or false

False (all reactions, no matter how minor should be documented. If a client has a serious allergic reaction to a medication, and it is given again, this could cause a serious injury or even death)

Nursing diagnosis is very similar to medical diagnosis. true or false

False (nursing diagnosis is about the clients health problems that are documented in the care plan. Medical diagnosis is done by the physician and states what the medical problems are)

Most documentation systems share the nursing process as a framework. True or false?

False (prudent care providers learn to work well with the documentation system that their employer requires)

You should only record the significant details of changes in a clients condition and avoid excessive wordiness. True or false.

False( provide all the necessary information. Missing details have often been cited in lawsuits and this may reflect on inadequate or incorrect care)

In your client documentation, you generally do not use names of roommates or visitors, as this is a breach of their confidentiality. True or false?

True

Nearly all documentation systems use the nursing process as a guide for recording client details. True or false?

True

"Client condition satisfactory" should not be used as there is no indication that an assessment was done. True or false.

True (meaningless statement)

What is intake and output graphic sheet used for?

Used to maintain an ongoing record of all fluid intake and output.