Documenting and Reporting

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? a. It documents assessments on separate forms. b. It records progress under problems, intervention, and evaluation. c. It provides and refers to a client's problem by a number. d. It provides quick access to abnormal findings.

d. It provides quick access to abnormal findings. - Explanation: Charting by exception (CBE) 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.

Which strategy would provide the most effective form of change of shift report? a. Recording the report for the oncoming shift prior to leaving the unit. b. Discussing the client's visitors and complaints during the prior shift. c. Providing the oncoming nurse the client's clipboard prior to leaving the unit. d. Utilizing a reporting form and allowing time for any questions.

d. Utilizing a reporting form and allowing time for any questions. - Explanation: A change-of-shift report is a discussion between health care team members leaving their shift and health care team members coming on duty for the next shift. It includes a summary of each client's condition and current status of care and should be in a standardized format to ensure concise and accurate information. It is not useful to discuss the client's complaints and visitors during the prior shift. Tape recording and giving the nurse the client's clipboard doesn't allow the oncoming nurse to ask questions.

A holistic form of charting that focuses on the patient's concerns and uses Data-Action-Response (DAR):

- Focus charting

A type of charting in which the care plan is incorporated into the progress notes and identifies problems by number is called:

- PIE charting (problem, intervention, evaluation)

SOAP format stands for:

- Subjective data - Objective Data - Assessment - Plan

After making a mistake while documenting on a patient's chart, the nurse should:

- draw a single line through the incorrect entry and write the words "mistake entry" beside it and sign

True or false: the patient record is permenant

- true

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? a. "A coronary artery bypass graft will benefit your heart." b. "The CABG procedure will help identify nutritional needs." c. "A complete ablation of the biliary growth will decrease liver inflammation." d. "The CABG procedure will help increase intestinal motility and prevent constipation."

a. "A coronary artery bypass graft will benefit your heart." - Explanation: Coronary artery bypass graft is abbreviated CABG. It does not identify nutritional needs, decrease liver inflammation, or increase intestinal motility.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? a. subjectivity b. objectivity c. organization d. reimbursement

a. subjectivity

When documenting effectively it should be:

- complete, accurate, concise, current, and factual

True or false: the nurse can document an intervention before carrying it out

- false: the nurse should never document interventions before carrying them out

Four basic components of RAI (Resident Assessment Tool):

- minimum data set - triggers - resident assessment protocols - utilization guides

Occurrence charting's usual formatting includes ______________, while variance charting includes ________________.

- unexpected event, cause, actions taken in response, discharge planning - cost, quality, length of stay

Which is not a purpose of the client care record? a. To serve as a legal document b. To facilitate reimbursement c. To serve as a contract with the client d. To assist with care planning

c. To serve as a contract with the client - Explanation: Client care records are legal documents, communication tools, and assessment tools. They are used for care planning, quality assurance, reimbursement, research, and education. They in no manner reflect a contract between health care staff and the client. The only exception to this is at the point of admission when the client (or responsible party) signs an acknowledgement of expenses about to be incurred as health care insurance information is obtained.

ISBAR stands for:

- Introduction - Situation - Background - Assessment - Recommendation (sometimes Read back is added)

A collaborative form of charting is called:

- case management model

The difference between a patient's health record and their electronic medical record is:

- patient can access PHR from home computer or internet whereas EMR is at the facility and patient must request copy to view

Which organization audits charts regularly? a. The Joint Commission b. National League for Nursing c. American Nurses Association d. Sigma Theta Tau International

a. The Joint Commission - Explanation: The Joint Commission (TJC)audits client records regularly under specific guidelines that are announced annually and shared with each institution. TJC also encourages institutions to set up ongoing quality assurance programs. The National League for Nursing, American Nurses Association, and Sigma Theta Tau International are professional nursing organizations that provide services to nurses; they do not access client records. .

Which finding from a nursing audit reflects high standards for client safety and institutional health care? a. The nurse records inappropriate nursing interventions. b. The nurse fails to identify the nursing diagnoses or clients' needs. c. The nurse documents clients' responses to nursing interventions. d. The nurse fails to adequately complete data on clients' health histories and discharge planning.

c. The nurse documents clients' responses to nursing interventions. - Explanation: Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by The Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health histories and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation.

A form of charting that uses shorthand documentation to document only significant findings and exceptions to standards:

- charting by exception

What are the purposes of patient records?

- communication - diagnostic and therapeutic orders - care planning - quality process and performance improvement - research - decision analysis - education - credentialing, regulation, and legislation - legal documentation - historical documentation

The most important purpose of patient records is:

- communication between health care team

True or false: the nurse can accept verbal orders from the doctor under all circumstances

- false: VO only accepted in emergency situations and written or electronic order must be completed ASAP

What document would the nurse consult to see trends in patient's VS?

- graphic record

A nurse is called to report an abnormal finding to a doctor and suggest a solution, what would be the order of information they give?

- identify self - identify patient and situation - give patient background - include any assessment details - offer recommended solution - repeat back doc orders

Occurrence charting is performed when:

- patient fails to meet an expected outcome or a planned intervention is not implemented

Medicare requirements for home health care:

- patient is homebound and still needs skilled nursing care - rehabilitation potential is good (or patient is dying) - the patient's status is not stabilized - the patient is making progress in expected outcomes of care

Medical records that are organized around a patient's problems identified by the entire health care team rather than around sources of info and use the SOAP format are:

- problem-oriented medical records

Benefits of RAI include:

- residents respond to individualized care - staff communication more effective - resident and family involvement increases - documentation becomes clearer

A health care group keeps data on its own separate form, this is what type of record?

- source-oriented record

A patient fills out information from their own records, and the info is stored on patients' computers or their internet:

- standalone PHRs

A connected PHR linked to a specific health care organization's EHR system or to a health plan's information system:

- tethered/connected PHRs

What circumstances allow for PHI to be shared without patient consent?

- tracking disease outbreaks - PHI needed by a coroner - child abuse and neglect suspected

Measures to protect confidential patient information include:

- turn screens away from public areas - encryption software - separate printer from another unit - secure disposal containers for documents - phones w/ built in encryption tech - verify fax/email/text before sending - restrict use of voice pagers for nonconfidential messages

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse? a. "I will arrange access for you to review the record after you put your request in writing." b. "No, the health care provider will not give you access to review the records." c. "Are you questioning the care of your child?" d. "Only the client has the right to review the health care records."

a. "I will arrange access for you to review the record after you put your request in writing." - Explanation: Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. Because the child is a minor, it is the parents' right to view the client's record. Therefore, the statements about the health care provider not giving the parents access to review the records and asking if the parents are questioning the care of their child are incorrect.

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply. a. "I will write, print, or type information legibly." b. "I will use only agency-approved abbreviations." c. "I will draw a straight line through any blank space." d. "I will stay logged in on the computer until the end of my shift." e. "I will elaborate on the details on my entry in the clients' records."

a. "I will write, print, or type information legibly." b. "I will use only agency-approved abbreviations." c. "I will draw a straight line through any blank space." - Explanation: Writing, printing, or typing information legibly will prevent the entry from losing its value for exchanging information if it is unreadable. Using only agency-approved abbreviations promotes consistency in interpretation. Drawing a straight line through any blank space will reduce the possibilities that someone else will add information to the current documentation. Staying logged in on the computer until the end of the shift is incorrect, as it is a security risk. Best practice is that the nurse logs off each time the nurse has completed an entry. Elaborating on the details on the entry in the clients' records is not in keeping with best practice. The entry should be brief but complete.

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? a. A client has asked a nurse if he can read the documentation that his health care provider wrote in his chart. b. A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. c. A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. d. A client who resides in Indiana has required hospitalization during a vacation in Hawaii.

a. A client has asked a nurse if he can read the documentation that his health care provider wrote in his chart. - Explanation: 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.

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate? a. Ask the client if information can be given to the parent. b. Provide the information to the parent. c. Explain the reasons for the hospitalization, but give no further information. d. Take the parent to the client's room and have the client give the requested information.

a. Ask the client if information can be given to the parent. - Explanation: No information should be provided by the nurse without permission from the client. Taking the parents to the client's room to get information from the client may violate the client's privacy.

The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply. a. Showing the provider the trends from baseline to present in blood pressure b. Informing the provider of the client's present heart rate of 116 beats/min c. Faxing the results of blood chemistry levels to the provider's office d. Writing the hemoccult result on a piece of paper and leaving it at the desk e. Placing a note on the computer terminal with the client's name and information

a. Showing the provider the trends from baseline to present in blood pressure b. Informing the provider of the client's present heart rate of 116 beats/min c. Faxing the results of blood chemistry levels to the provider's office - Explanation: Reporting to the primary care provider can occur face-to-face, by telephone, by text messaging, or, in some settings (e.g., long-term or home care), by fax. Placing a note on a computer terminal with client information or writing the hemoccult results on a piece of paper and leaving it at the desk is a violation of the Health Insurance Portability and Accountability Act because the information is visible and accessible to anyone passing by. The other answers are appropriate ways to communicate client information to a health care provider while protecting the client's confidentiality.

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? a. The client reports waking up this morning with a severe headache. b. The client has symptoms in the morning associated with a heart attack. c. The client is coughing and experiencing severe heartburn in the morning. d. The client has a history of severe complaints in the morning.

a. The client reports waking up this morning with a severe headache. - Explanation: The statement uses approved abbreviations for complains of (c/o) and headache (H/A). Therefore the statement indicates that the client is complaining of a severe headache this morning. The abbreviation c/o stands for complains of, not coughing. The abbreviation H/A stands for headache, not heart attack or heartburn.

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

a. 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 client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? a. "Let me get that for you." b. "Only authorized persons are allowed to access client records." c. "The provider will need to give permission for you to review." d. "I am sorry I can't access that information."

b. "Only authorized persons are allowed to access client records." - Explanation: The client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. The other answers are therefore inappropriate responses.

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? a. A never event b. A variance c. An audit d. A sentinel event

b. A variance - Explanation: This scenario reflects a variance in care. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client.

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 nurse implementing? a. FOCUS charting b. SOAP charting c. PIE charting d. narrative charting

b. SOAP charting - Explanation: The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response? a. "According to HIPAA, medical records cannot be changed." b. "HIPAA legislation allows for you to change any information." c. "According to HIPAA legislation, you have a right to request changes to inaccurate information." d. "HIPAA legislation only allows access to review the medical record."

c. "According to HIPAA legislation, you have a right to request changes to inaccurate information." - Explanation: The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records. They may also update their health record if inaccurate, get a list of the disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations, request a restriction on certain uses or disclosures, and choose how to receive health information.