Evolve- Documentation

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."

A registered nurse is teaching a group of student nurses about the nursing process in a hospital. Which statement made by a student nurse indicates the need for additional teaching?

"The subjective and objective data are included in problem, intervention, evaluation (PIE) charting."

A hospital unit maintains documentation in the form of a problem-oriented medical record (POMR). The nurse notices that a patient reports symptoms of acid reflux. On further assessment, the nurse finds that the patient has fully recovered from typhoid. Where and how does the nurse update the record? Select all that apply.

Add the new problem to the problem list of the patient. Highlight typhoid and add the date of recovery.

The nurse is recording specific demographic information about a patient in a hospital. Which section of the traditional source record does the nurse use to record this information?

Admission sheet

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). 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

The nurse is learning how to chart. On what does charting by exception focus? Select all that apply.

It documents deviations. It uses a shorthand method. It documents significant findings.

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. It saves time. It provides continuity of care. It protects the nurse from legal issues.

The nurse is preparing a patient for discharge. What should the nurse include in the discharge summary forms? Select all that apply.

Dietary restrictions. Follow-up care. Emergency contact numbers.

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. Do not leave the patient's medical record open unattended on a computer screen. 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

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. Failing to record the history of cancer. Failing to record the patient information with legible writing.

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

The nurse is caring for a patient who has returned to the floor after a knee replacement in the morning. Which statements written in the nurse record are accurate? Select all that apply.

Heart rate: 75/minute, urine voided 300 mL, pain rated as 7 on a scale of 0 to10. Temperature: 102 degrees Fahrenheit at 5:00 pm, paracetamol 500 mg at 5:00 pm, temperature 99 degrees Fahrenheit at 6:30 pm

The nurse is caring for a patient who is diagnosed with renal failure due to diabetes. The nurse has to pass the patient care to another nurse during change of shift. Which information should the nurse include in the hand-off report? Select all that apply.

Nursing diagnosis of the patient. Important information about family members. Recent changes in objective measurements.

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.

What is an appropriate way for the nurse to dispose of printed patient information?

Place in a secure canister marked for shredding

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 all errors promptly. Chart only for yourself.

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. Begin each entry with date and time and end with signature and title.

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.

Which standardized assessment tools are used for receiving health care funding from the Centers for Medicare and Medicaid Services? Select all that apply.

Resident Assessment Instrument. Minimum data set.

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.

The nurse is learning about subjective-objective-assessment-plan (SOAP) charting. In which ways does SOAP charting differ from problem-intervention-evaluation (PIE) charting? Select all that apply.

SOAP charting originates from medical records. SOAP charting includes assessment information.

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.

The patient is extremely uncooperative and grumbles all the time. The patient is feeling healthy and refreshed. The patient, who is 65 years old, is stable with no pain.

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 assesses a patient postoperatively and charts the findings in a SOAP note. What elements are integral to the SOAP note? Select all that apply

Subjective Assessment

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. 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. The EHR performs checks to support regulatory requirements. 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 patient is diagnosed with acute renal failure due to diabetes. Following treatment, the patient recovers. The patient is being discharged to home on insulin. The nurse is preparing a discharge summary for the patient. What information should the nurse provide in the discharge summary? Select all that apply.

The contact information of the healthcare provider. The step-by-step instructions for self-administration of insulin. The signs and symptoms that have to be reported to the healthcare provider.

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.

A primary healthcare provider calls the intensive care unit and orders 10 mg of morphine every 4 hours for a patient's pain. What correct actions does the nurse take to record and follow the instructions? Select all that apply.

The nurse administers 10 mg of morphine every 4 hours and documents it. The nurse reads back the prescription to the primary healthcare provider for verification and documents that the order was read back. The nurse records the details of the instructions and marks it as a telephone order (TO). The nurse confirms the patient's name, room number, and diagnosis.

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. Copious amounts of sputum produced since morning.

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. 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.

The nurse is administering an enema to a patient. What should the nurse record after the procedure? Select all that apply.

The time the enema is administered. Equipment used for administration.

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.

This report helps in identifying loopholes in the operation of the healthcare system. This report helps in providing good, quality healthcare. This report helps to identify the need to change a procedure or policy.

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

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 Oral communication