Documenting and Reporting
A client is scheduled for a CABG procedure. What information should the nurse provide to the client?
"A coronary artery bypass graft will benefit your heart."
28s The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. Which action by the nurse is most appropriate?
Assess the triggers from the data.
What ensures continuity of care?
Communication
Which charting formats permit documentation on any significant topic, not just client problems?
FOCUS
20s The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?
Inform the health care provider that a written order is needed
Which abbreviation is correct for use in documentation?
PO Per os BT Sub q
A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?
Progress notes
What information should the nurse document in the medication record when administering a non-narcotic pain medication? Select all that apply.
Time Dose Reason given Effectiveness of medication
A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows what is important when working with a client translator?
Translators may need additional explanations of medical terms
documentation must be just read
must be, complete concise, accurate, current, and factual. Make sure your documentation reflects the nursing process
can you chart something that happened on a previous shift, in the future, or for someone else? what should documentation be in order by? how long are medical records kept?
no time forever, until you die
Things that you shouldn't document.... and what you should document instead ----> just read
"blood pressure isgood/average/normal/sufficient" -instead: blood pressure is 120/80 "patient seems comfortable today" -instead: patients pain level 1/10
The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. Which action by the nurse is most appropriate? A- Repeat the minimum data set in 2 weeks. B-Document the findings on an occurrence report. C-Assess the triggers from the data. D- Provide a comprehensive written report to the client ombudsperson.
C
32s When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?
Ensure that the client's name appears on all pages.
7s A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?
Graphic sheets
ISBAR stands for?
Identity/Introduction, Situation, Background, Assessment, Recommendation
The nursing is caring for a client who requests to see a copy of his health care records. What action by the nurse is most appropriate?
Review the hospital's process for allowing clients to view their health care records.
documentation system in which each health care group records data on its own separate form
source-oriented record
A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and: reimbursement staff development change of mechanisms research
A
Documentation is: which consists of: (also known as)
a legal record of all patient interactions - assessing, - diagnosing, - planning, - implementing, and - evaluating (the nursing process)
a process for effective hand-off communication among health care professionals about a patient's condition, standing for Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read back
ISBAR
what format is Source-Orientated records? what does Source-Orientated records consists of?
paper format progress notes, narrative notes
information sheets that contain the individual's medical history, including diagnoses, symptoms, and medications
personal health record
what is the purpose of patient records? just read
allow communication between different disciplines diagnostic and therapeutic orders care planning quality process and performance improvement research decision analysis education credentialing, regulation, and legislation legal documentation reimbursement historical documentation (helps us look at trends)
what is a patient record? who specifies what data must be recorded?
complied patient health information The Joint Commission
documentation entries must be ____ and _____ by the person who created the entry (no one else can do this)
dated and timed
what is conferring about care? what are the types?
exchanging ideas or to seek information, advice, or instructions -consultation and referrals (calling a podiatrist to get patients toenails trimmed) - nursing and interdisciplinary team care conference -nursing care rounds
what is a case management model? why is a case management model used? is it individualized?
if someone has surgery or something, it is outcomes that "typical" patients are expected to achieve each day of care to have cost effective care no
documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes
problem-oriented medical record
The nurse is in the process of reporting to the health care provider the changes in the client's status. What is the best action by the nurse? Select all that apply. showing the provider the trends from baseline to present in blood pressure writing the hemocult result on a piece of paper and leaving it at the desk informing the provider of the client's present heart rate of 116 BPM faxing the results of blood chemistry levels to the provider's office placing a note on the computer terminal with the client's name and information
showing the provider the trends from baseline to present in blood pressure informing the provider of the client's present heart rate of 116 BPM faxing the results of blood chemistry levels to the provider's office
A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note, in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting? FOCUS charting Charting by exception (CBE) Problem, Intervention, Evaluation (PIE) charting Variance charting
B
The nurse is tasked to organize weekly care plan conferences with other health care team members. What does the nurse communicate are the purposes of this meeting? Select all that apply.
rehabilitation plan from the physical therapist and if changes need to be made review of client's current progress in the plan of care discussion of the diabetic client's meal plan addressing the need for durable medical equipment when the client goes home
what are the methods of documentation? which is the way for healthcare providers to securely exchange information?**
-Computerized Documentation and Electronic Health Records (EHRs) • Personal Health Records (PHRs) • Health Information Exchange (HIE)**
A concise document that provides most of the client's nursing and medical information is a(n): office record. nursing care plan. Kardex. past chart.
B
Which finding from a nursing audit reflects high standards for client safety and institutional health care?
The nurse documents clients' responses to nursing interventions.
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 records progress under problems, intervention, and evaluation. B- It documents assessments on separate forms. C- It provides quick access to abnormal findings. D- It provides and refers to a client's problem by a number.
C
A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy?
Use minimum disclosure policy to release the information.
ANA nursing documentation principles: JUST READ
1. Documentation Characteristics 2. Education and Training 3. Policies and Procedures 4. Protection Systems 5. Documentation Entries 6. Standardized Terminology
A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease, and their families. Providing this information is an example of: A- consultation. B- conferring. C- referral. D- reporting.
C
1m 44s A nurse is attending a job fair at the local community center and stops at a booth that is demostrating technology for client care. While touring the booth, the nurse meets an informatics nurse specialist (INS). Being unfamiliar with this position, the nurse asks the INS, "How did you get this position?" Which response by the nurse would be most appropriate?
"I've had graduate-level education focusing on informatics."
A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? "It will let me see everything that has been done and things that need to be done." "It will give me a better sense of what my workload will be today." "It makes our client feel like we care, especially if we start the day off with a clean room." "It will allow for us to see the client and possibly increase client participation in care."
D
Besides being an instrument of continuous client care, the client's health care record also serves as a(an): A- assessment tool. B- incident report. C- Kardex. D- legal document
D
when will you be reporting patient care information?
change of shift telephone transferred/discharged to family members incident reports
you need to understand who can see a patients chart. a child cant just see their parents chart. what do they need to have?
healthcare proxy
The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development? "The care plan shows the medical diagnosis for the client." "The care plan is required for every client by the Joint Commission." "The care plan is the only way for nurses to document what they do." "The care plan provides additional documentation about the work of the nurse."
"The care plan is required for every client by the Joint Commission."
Good documentation characteristics is documentation that is:
- Accessible - Accurate, relevant, and consistent - Auditable - Clear, concise, and complete - Legible - Thoughtful - Timely and sequential - Reflective of the nursing process - Retrievable on a permeant basis
A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? A- a client who is homebound and needs skilled nursing care B- a client whose rehabilitation potential is not good C-a client whose status is stabilized D-a client who is not making progress in expected outcomes of care
A
A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? a- identifying risks and ensuring future safety for clients b- gauging the nurse's professional performance over time c- protecting the nurse and the hospital from litigation d- following up the incident with other members of the care team
A
A nursing instructor is discussing a nursing student's social media post about an interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is most appropriate? "Any information that can identify a person is considered a breach of client privacy." "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family." "You may continue to post about a client you cared for during clinicals, as long as you do not use the client's name." "All aspects of the clinical experience are confidential and should not be discussed."
A
An informatics nurse is assisting with the development of a new clinical information system that will be implemented in the facility. As part of the process, the team is evaluating the purpose of the system and the technological options available. The team is in which phase of the system development lifecycle? Analyze and plan Train Test Design
A
Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.
A
The nurse calls the physician due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR? "Could you give me an order to draw blood for CBC and culture?" "I am concerned that the client might have a serious infection or even may be becoming septic." "The client's temperature is 102 F (38.9 C) for the last 6 hours." "You should come evaluate the client right away."
A
What is the primary purpose of the client record? Communication Education Research Advocacy
A
What situation would permit the nurse to disclose information without the client's approval? the nurse suspecting that a client is being abused or neglected the nurse sharing details of the client's wills and loans the nurse revealing the address of the client's place of residence the nurse informing the relatives of the client's noncompliance with treatment
A
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: limiting abbreviations to those approved for use by the institution. ensuring that abbreviations are understandable to clients who may seek access to their health records. using only abbreviations whose meaning is self-evident to an educated health professional. using only those abbreviations that are defined in full at another location in the client's chart.
A
The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? pain rating of 4 on a scale of 0-10 urine output 100 ml describes wound as itchy concerned with feeling tired
B
The nurse is using the ISBARR format to report a surgical client's deteriorating condition to a health care provider. Which actions would the nurse perform when using this guide? Select all that apply. The nurse asks the health care provider to describe the admitting diagnosis of the client. After introductions, the nurse states the client name, room number, and problem. The nurse states that the client's condition "could be life-threatening." The nurse asks the health care provider to estimate the discharge date for the client. The nurse asks the health care provider to comment on the present situation before giving recommendations. The nurse reads back the physician's new orders at the conclusion of the call.
After introductions, the nurse states the client name, room number, and problem. The nurse states that the client's condition "could be life-threatening." The nurse reads back the physician's new orders at the conclusion of the call.
A nurse helps a client who has cystic fibrosis prepare a stand-alone personal health record. Which statement by the nurse best explains this type of information? "Your entire health care team may access and securely share your vital medical information electronically." "You can fill in information from your own records and store it on your computer or the Internet." "You can link your record to a specific health care organization's electronic health record system." "Your health care provider is obligated to read your personal health record and share it with your insurance provider."
B
Which documentation tool will the nurse use to record the client's vital signs every 4 hours? Acuity charting forms A flow sheet 24-hour fluid balance record Medication record
B
Which is not a purpose of the patient care record? Care planning Contract Reimbursement Legal document
B
The nurse is creating a care plan for a client. Which information should the nurse include in the client's plan of care? Select all that apply. A- the client care assignment of the nursing and support staff B- the client's problem, goals, and nursing orders C- routine care, such as client's bath and mouth care D- the client's level of activity and current medical orders E- the minutes of the most current team conference meetings
B,C,D
A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? The abdominal area Heart rate and rhythm The lower extremities Lung sound
C
A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which people would be entitled to access of the client's records? A-health care professionals of the facility B-close friends of the client C-Those directly involved in the client's care D-any family member of the client
C
An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate? Verify the insurance coverage before giving information. Mediate a meeting between the parent and client. Explain the reason why information cannot be disclosed. Refer the parent to the physician providing care.
C
The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records? Problem-oriented recording has numerous locations for information where each member of the multidisciplinary team makes entry about their own specific activities in relation to the client's care. Problem-oriented recording is difficult to demonstrate a unified approach for resolving the clients' problem among caregivers. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Problem-oriented recording gives the clients the right to withhold the release of their information to anyone.
C
Which documentation by the nurse best supports the PIE charting system? Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given Vomiting 250 mL undigested food, antiemetic given, no further vomiting Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea
C
Which statement is not true regarding a medication administration record (MAR)? A- The MAR identifies routine times for medication administration. B- The MAR distinguishes between routine and "as needed" medications C- When using an electronic MAR, the nurse has to log off so that the next person using the computer does not sign off a medication under her name by mistake. D- If the client refuses the dose you don't have to document this on the MAR.
D
A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which information would the nurse expect to include when preparing the verbal handoff report? Client's intake for previous meal Client's family members Client's admission number Current client assessment
D
According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? Accreditation Clinical judgment Psychomotor skills Documentation
D
The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr, The client is NPO and has received morphine sulfate 4 mg IV for pain with a decrease of epigastrc pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method? 4/10 pain with nausea; on IV fluids 125 mL/h of normal saline, NPO, pain 4/10 on pain scale with 4 mg IV morphine every 4 hours NPO, 4/10 pain, epigastric pain, nausea 4/10 pain on pain scale, epigastric pain; with reports of nausea
D
The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report? Telemedicine report Transfer report Nurse's shift report Incident report
D
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: factual statement. important information. relevant data. interpretation of data.
D
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-Narrative charting C-PIE charting D-SOAP charting
D
Which principle should guide the nurse's documentation of entries on the client's health care record? Documentation does not include photographs. Correcting fluid is used rather than erasing errors. Nurses should not refer to the names of physicians. Precise measurements should be used rather than approximations.
D
28s An informatics nurse specialist is working with a team who is developing an expanded system for documenting critical values in the electronic health record (EHR) being used at the facility. The team has identified the need for this addition and provided appropriate evidence to support this change. The team would now proceed to which phase in the system development lifecycle?
Design and build
The nurse is looking for information to care for a client. Which information would the nurse be unable to locate in the client care summary or kardex?
Respiratory assessment
During hospitalization, the client has developed shortness of breath, with edema. What action should the nurse take?
Revise the plan of care.
The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?
The nurse meets with nurses or other health care professionals to discuss some aspect of client care.
if the computer or a system goes down and you are unable to order labs what would you fill out in order to still fill these
a downtime sheet
A nurse is giving change of shift report on a client who has just returned from surgery. What client information should the nurse include in the report? Select all that apply. client discharge teaching needs personal feelings about the client intake and output prior to surgery type of insurance name of the client current vital signs
name of the client intake and output prior to surgery client discharge teaching needs current vital signs
The nurse is documenting care for a client with diabetes. Which nursing documentation will The Joint Commission review? Select all that apply
nursing care provided physical assessment nursing diagnoses client teaching
who helps create nursing documentation software?
nursing informatics
What is Problem-Oriented Medical Records (POMR) organized around? do all healthcare providers record on one form? What format is used on this form? WHAT DOES SOAP STAND FOR
the patients problems rather than around the source of information Yes SOAP (subjective data, objective data, assessment, plan)
The client states, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today." Arms are folded across chest. Brow is furrowed and refuses to allow morning vital sign measurements. Which entry should be included in the the nurse's charting? Select all that apply A- Arms folded across chest and brow is furrowed B- Refuses to allow morning vital sign measurements C- Seems angry today D- Unhappy with care E- States, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today."
A, B, E Arms folded across chest and brow is furrowed States, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today." Refuses to allow morning vital sign measurements
A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes in to the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation? Fill out an incident report. Attach a copy of the incident report to the chart. Stop the infusion and document the time. Report error to primary provider.
B
A nurse is transfusing multiple units of packed red blood cells (PRBCs). After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? "I am calling because the client receiving blood has developed dyspnea and had crackles." "This client has a medical history of heart failure." "I think the client would benefit from intravenous furosemide." "It seems like this client has fluid volume overload."
C
MAKE A CARD ABOUT SBAR To improve communication within the health care system, tools were created to standardize the process and assist with clarity and conciseness. SBAR is one such tool. In this tool, what does R stand for? Response Report Recommendations Reinforcing data
C
The nurse hears an unlicensed assitive personel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? Document the UAP's conversation. Report the UAP to the nurse manager. Remind the UAP about the client's right to privacy. Notify the client relations department about the breach of privacy.
C
The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states: The use of rationales is not commonly practiced in the clinical setting. The rationale is deleted to provide additional charting space in the computer system. Although not written, the nurse must know or question the rationale before performing an action. Rationales are only important while the nurse is in training. Some facilities do not require them on their plans of care.
C
The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? Select all that apply. Conversations about clients must take place in private places where they cannot be overheard. Documentation must be kept of personnel who have accessed a client's record. Computer screens must be oriented towards the public view. Light boxes for examining X-rays with the client's name must be in private areas. The names of the clients on charts should be visible to the public.
Documentation must be kept of personnel who have accessed a client's record. Light boxes for examining X-rays with the client's name must be in private areas. Conversations about clients must take place in private places where they cannot be overheard.
Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. A-posting information linking a client with diagnosis, treatment, and procedure on whiteboards B-placing fax machines, filing cabinets, and medical records in areas off-limit to the public C- keeping record of people who have access to clients' records D-making the names of clients on charts visible to the public E-obscuring identifiable names of clients and private information about clients on clipboards
B,C,E
The nurse receives a verbal order from a physician during an emergency situation. Which actions should be taken by the nurse? Select all that apply. Include V.O. with the physician name on the order. Record the order on the pharmacy discrepancy sheet. Have the physician review and sign the order during the emergency. Mark the date and time of the order. Read back the order.
Read back the order. Mark the date and time of the order. Include V.O. with the physician name on the order.
what must nurses receive on documentation before starting a job at a new facility?
education and training on the facilitys' documentation system
who only using PIE charting? what does PIE stand for?
nurses problem, intervention, 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?
"HIPAA legislation only allows access to review the medical record." "HIPAA legislation allows for you to change any information." "According to HIPAA, medical records cannot be changed." "According to HIPAA legislation, you have a right to request changes to inaccurate information." D
A nurse is giving a verbal report to a health care provider using the ISBAR communication technique. The client being discussed has signs and symptoms of fluid volume deficit. Which statements should the nurse include in the report? Select all that apply. SCROLL "The client reports dizziness when walking." "Current blood pressure is 90/50 mm Hg with a pulse of 112 bpm." "The client vomited twice and has dry mucous membranes." "I've documented all the care, including the vital signs." "All of the orders have been completed." "I am the nurse assigned to the client."
"I am the nurse assigned to the client." "The client reports dizziness when walking." "The client vomited twice and has dry mucous membranes." "Current blood pressure is 90/50 mm Hg with a pulse of 112 bpm." "All of the orders have been completed."
Which statement regarding FOCUS charting is most accurate? Problem, Intervention, Evaluation (PIE) charting is used with focused charting. Each note should include each section of the Data, Action, Response (DAR) format of charting. The charting focuses on the injury or illness only. The charting focuses on client strengths, problems, or needs.
D
A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply A- documenting entries that have unidentifiable writers' name and title B- using approved agency abbreviations C- documenting entries that are subjective D- documenting entries that are up to date and comprehensive E- recording the date and time of all entries
D- documenting entries that are up to date and comprehensive E- recording the date and time of all entries B- using approved agency abbreviations
what is reporting care? what can a nurse use to report care? What does SBAR stand for-
oral, written, or computer based patient information that you give to other people. SBAR (situation, background, assessment, recommendation)
The nurse is caring for several clients on a busy shift at the hospital. When documenting on these clients, which high risk errors should the nurse avoid making? Select all that apply. A- charting in advance B- inadequate admission assessment C- failure to document completely D- batch charting E- falsifying client records
A,B,C,E inadequate admission assessment failure to document completely charting in advance falsifying client records
A nursing student asks why completing an acuity report is important. What is the best response by the nurse? "It's the beginning step in determining the plan of care for the client." "It helps determine our staffing requirements." "It provides the pharmacy with the newest health care provider prescription." "It determines if a client needs to be transferred to a different unit."
B
A nursing student is preparing a presentation on client records and documentation. What information should the student include in the presentation? Nurses should not document progress notes in a client's record. Communication is the primary purpose of client records. Clients should keep the original record at home in a fireproof safe. Physicians will not review nurses' documentation in the client's record.
B
what is focus charting? what format does focus charting use?
putting the focus of care back to the patient and the patient concern. (instead of us listing what problems we think a patient is having, a patient tells us what they think their problems are) DAR (Data, Action, Response)
