eaq ch 26
A hospital faces a malpractice lawsuit due to a medical record error made by the on-call nurse. What kind of charting errors can lead to malpractice lawsuits? Select all that apply.
Failing to record drug allergies Failing to record discontinued medications Correct 4 Failing to record the history of cancer Correct 5 Failing to record the patient information with legible writing
Following a renal transplant, the nurse checks the patient's urine output every 2 hours. Which is the appropriate place to document results in the patient's chart?
Flow sheet
The nurse spends a considerable amount of quality time documenting pertinent clinical patient data accurately and comprehensively. What does effective documentation ensure? Select all that apply.
It facilitates proper insurance reimbursement. Correct 3 It saves time. Correct 4 It provides continuity of care. Correct 5 It protects the nurse from legal issue
How is proper documentation of a patient's health information useful to medical insurance companies? Choose the best answer.
It helps in determining the diagnosis-related group (DRG) of the patient.
The nurse is learning how to chart. On what does charting by exception focus? Select all that apply.
It documents deviations. Correct 3 It uses a shorthand method. Correct 4 It documents significant findings
A group of nurses are discussing the advantages of using computerized provider order entry (CPOE). Which statements indicate that the nurses understand the major advantage of using CPOE?
"CPOE reduces transcription errors.
The nurse, who is caring for a patient on a ventilator, electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspirating because the head of the bed is not elevated high enough. This warning is known as what type of system?
A clinical decision support system
A primary healthcare provider is prescribing medications using an electronic health record (EHR). Suddenly, an alert comes up stating that the patient is allergic to the prescribed medication and needs a change in medications. What kind of system gives such warnings?
Clinical decision support system (CDSS
When the nurse needs to notify a patient's guardian about the patient's health status, where does the nurse access the information to contact the guardian?
Admission sheet
Documentation is an important activity in nursing and should conform to certain standards of organizations. Which are examples of these organizations? Select all that apply.
American Nursing Association (ANA) Correct 2 The Joint Commission National Committee of Quality Assurance
The nurse interprets the subjective and objective data and diagnoses a problem in a patient. Which step of the nursing process reflects this interpretation, according to SOAPIE (subjective, objective, assessment, plan, intervention, and evaluation) format?
Assessment
A patient complains of not feeling well and is coughing frequently with copious phlegm. Coughing is worse at night. During the initial assessment, the nurse finds that the patient coughs violently for 40 to 45 seconds with thick, yellow phlegm. The blood pressure is 150/90 mm Hg, pulse rate is 92 beats/minute, and respiratory rate is 22 breaths/minute. Wheezing and rhonchi are present in both lung bases. The patient expresses having chest pain when coughing and the pain radiates to the arm. Which data should the nurse document as objective data? Select all that apply.
Blood pressure Correct 3 Thick, yellow phlegm Presence of wheezes and rhonchi Objective data are data that are observed and measured directly by the healthcare professional. Blood pressure can be measured through a sphygmomanometer. The characteristics of phlegm can be observed. The wheezing and rhonchi can be auscultated. Chest pain and pain radiating to the arm are the verbal complaints of the patient. These are considered subjective data.
A patient sustains an injury from a fall while on a hospital unit. The nurse makes an incident report. What is the purpose of the incident report? Select all that apply.
Correct 1 This report helps in identifying loopholes in the operation of the healthcare system. Correct 2 This report helps in providing good, quality healthcare. This report helps to identify the need to change a procedure or polic
What is an appropriate way for the nurse to dispose of printed patient information?
Correct3 Place in a secure canister marked for shredding
The nurse, after administering antibiotics, is updating a patient's chart in the emergency room. What elements of the report does the nurse accurately document in order to limit nursing liability in case of a legal claim? Select all that apply.
Current medications given Correct 2 Discontinued medications Correct 3 Drug allergies
A nurse manager is educating the nursing staff on the importance of security with the implementation of the electronic health record (EHR) on the unit. What points does the manager emphasize? Select all that apply.
Do not share passwords with anyone. Correct 2 Do not leave the patient's medical record open unattended on a computer screen. Correct 5 Do not log in with someone else's user access
On the nursing unit, you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system?
Electronic health record
A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "The patient is difficult to care for and refuses suggestions for improving appetite." Which directions does the manager give to the staff nurse who entered the note?
Enter only objective and factual information about the patient
You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which option is the best response?
HIPAA provides you with greater control over your personal healthcare information.
A patient asks for a copy of her medical record. What is the nurse's best response?
Indicate that she has the right to read her record
Which charting entries are most accurate?
Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise
The nurse understands that patient records are legal documents and should be accurate. What precautions should the nurse take when documenting? Select all that apply.
Record all facts. Record all written entries legibly and in black ink. Correct 4 Begin each entry with date and time and end with signature and title.
The nursing instructor is teaching students about legal guidelines for documentation. What guidelines for documentation should the nurse include? Select all that apply.
Record all facts. Correct 2 Correct all errors promptly. Correct 3 Chart only for yourself
A primary healthcare provider calls the nursing unit and requests the nurse on duty to update a patient's chart with the physician orders provided. What actions does the nurse perform? Select all that apply.
Record the date and time of the entry. Record the source of the information and the mode of communication
Using the SOAP format, which represents the appropriate P statement?
Reposition the patient on the right side. Encourage the patient to use the patient-controlled analgesia (PCA) device
The nurse is discussing a case history in a clinical conference. Which patient information should the nurse exclude from mentioning to maintain confidentiality of the patient? Select all that apply.
Room number Demographic details Date of birth
When updating a patient's chart, the nurse erroneously documents a wrong medication. Upon realizing the mistake, what does the nurse do?
Strike with a single line, tag it as an error, put initials, and document the correct medication.
The nurse is caring for a patient who has undergone abdominal surgery. The patient informs the nurse of discomfort in the abdomen and is unable to turn to the left side. The nurse finds that the patient has a temperature of 100.2° F, a respiratory rate of 28 breaths/minute, and a heart rate of 98 beats/minute. Which data should the nurse chart under the O in SOAP charting? Select all that apply.
Temperature 100.2° F Respiratory rate 28 breaths/minute Correct 5 Heart rate 98 beats/minute
The nurse is giving information to a group of caregivers about electronic health records (EHRs). What information about the EHR should the nurse offer them? Select all that apply.
The EHR integrates all pertinent patient information into one record. Correct 4 The EHR performs checks to support regulatory requirements. Correct 5 The EHR provides the means to compare ongoing clinical data with baseline information
The nurse faxes a patient's medical record to an unknown number. Which law is the nurse violating?
The Health Insurance Portability and Accountability Act (HIPAA
A new graduate nurse is providing a telephone report to a patient's healthcare provider and accepting telephone orders from the provider. Which actions require the new nurse's preceptor to intervene?
The new nurse gives a newly ordered medication before entering the order in the patient's medical record.
You are supervising a beginning nursing student who is documenting patient care. Which actions require you to intervene?
The nursing student documented medication given by another nursing student.
The primary healthcare provider orders a clear liquids diet for a patient with gastritis. On the first day, the patient consumes soup and tolerates it well. How does the nurse document this finding?
The patient had 2 cups of soup, which was tolerated well
The nurse is caring for a patient who has been diagnosed with pneumonia. The nurse is reviewing the assessment details of the patient: "Blood pressure is 150/90 mm Hg; pulse is 92 beats/minute, and the respiratory rate is 22 breaths/minute. The patient seems to have difficulty breathing. Sounds are produced when the patient exhales. Auscultation reveals rhonchi in the lower lung bases. Copious amounts of phlegm have been produced since morning." A senior nurse finds this to be poor quality of documentation. Which statements in the documentation are considered to be poor quality documentation and informatics? Select all that apply.
The patient seems to have difficulty breathing. Sounds are produced when exhaling. Correct 5 Copious amounts of sputum produced since morning
As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which option is the most appropriate documentation of the patient's emotional status?
The patient stated that he felt frustrated by the lack of information he received regarding his tests
You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which pieces of information do you include in the report? Select all that apply.
The patient's name, age, and admitting diagnosis Correct 2 Allergies to food and medications That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of acetaminophen
A patient was shifted from the intensive care unit to the cardiac unit. What kinds of reports are used to communicate between the two units?
Transfer reports
A critical pathway in an orthopedic unit indicates that a patient should be afebrile, normotensive, and eupneic after knee replacement surgery. The nurse performs a postoperative examination of a patient's status after left knee replacement surgery and finds that the patient is experiencing a low-grade temperature. What is this finding called?
Variance Any unexpected outcome of a procedure, unmet goals, or an intervention not indicated in the critical pathway is called a variance. A positive variance is a positive, unexpected outcome, such as when a patient starts walking a day earlier than expected after surgery. There is no negative variance term that is used in documentation. A low-grade temperature is not a life-threatening sign in this patient, and thus cannot be considered as a critical finding.
Communication among the members of a healthcare team is essential to providing quality care to patients. Which are the modes for exchanging information among the members of the healthcare team? Select all that apply.
Written reports Correct 4 Oral communication
You are helping to design a new teaching sheet that will go home with patients who are discharged home from your unit. Which option do you need to remember when designing the teaching sheet?
You need to use words the patients can understand when writing the directions.
A nurse manager is reviewing a hand-off report prepared by a new nurse. What statements require the manager to advise the nurse on the correct techniques of documentation and informatics? Select all that apply.
he patient is extremely uncooperative and grumbles all the time. The patient is feeling healthy and refreshed. Correct 5 The patient, who is 65 years old, is stable with no pain
According to the court of law, "a care not documented is care not provided." What are the proper ways of documenting a patient's information? Select all that apply.
record pertinent health and drug information. Record medications that are given and any drug reaction. Correct 4 Document discontinued medication
