Fundamentals PrepU Chapter 16: Documenting
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."
The health care provider tells the client, "You are experiencing an MI," and leaves the room. The client asks the nurse what an MI stands for. What response by the nurse is most accurate?
"Myocardial infarction."
The nurse is documenting an assessment that was completed at 9:30 pm. The facility uses military time for documentation. What entry should the nurse make for the time care was given?
2130
Besides using the health care records, which form of communication should the nurse use to provide client details to the health care team coming on duty in the next shift?
Change-of-shift reports
A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents?
Client's record and occurrence report
Which statement is not true regarding a medication administration record (MAR)?
If the client refuses the dose you don't have to document this on the MAR.
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 emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.
What dual purpose does an audit serve?
Quality assurance and reimbursement
The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?
Subjective data should be included when documenting.
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:
interpretation of data.
The nurse makes an erroneous entry into the written health record. What is the appropriate nursing action?
Place one line through the entry, and initial.
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?
"According to HIPAA legislation, you have a right to request changes to inaccurate information."
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 allow for us to see the client and possibly increase client participation in care."
The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?
"Only authorized persons are allowed to access client records."
Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records?
"The clients' medical records are obstruction to research and education."
Which documentation tool will the nurse use to record the client's vital signs every 4 hours?
A flow sheet
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:
Although not written, the nurse must know or question the rationale before performing an action.
Which charting formats permit documentation on any significant topic, not just client problems?
FOCUS -FOCUS charting permits documentation on any significant topic. It is organized around data, action, and response.
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 -The graphic record is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics.
A concise document that provides most of the client's nursing and medical information is a(n):
Kardex.
An informatics nurse is involved in testing an update to a clinical information system. Numerous caregivers are using the system at the same time. The testing is being done to see if the system can handle the large amount of users at one time. The nurse is involved with which type of testing?
Performance
An informatics nurse is part of a team that is testing a new electronic health record system. The testing involves large groups of health care providers who will be using the system. During this testing, the system stalls and fails to respond when large numbers of providers are using the system at the same time. Which phase of testing is being conducted?
Performance
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?
Remind the UAP about the client's right to privacy.
The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?
Reporting
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.
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?
SOAP charting -The nurse is using the SOAP charting method to record details about the client. 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.
A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology?
Telemedicine and mobile technology
A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment?
The lower extremities -Peripheral vascular disease mostly affects the lower extremities.
A new graduate is working at a first job. Which statement is most important for the new nurse to follow?
Use abbreviations approved by the facility.
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.
What ensures continuity of care?
communication
Besides being an instrument of continuous client care, the client's health care record also serves as a(an):
legal document.
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.
The nurse is orienting a new graduate nurse and reviewing documentation. Which documentation performance would include best practices for charting? Select all that apply.
-Use only approved abbreviations. -Use partial sentences and phrases.
Which information the nurse is expected to find on the nursing Kardex? Select all that apply. -the current medical order for the client -the duty roster for the staff -the level of activity for the client -the meals and breaks for staff -the client's preparedness for an investigation
-the level of activity for the client -the current medical order for the client -the client's preparedness for an investigation
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?
Ask the client if information can be given to the parent.
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. -Once the minimum data set is complete, it will identify elements or triggers for issues that the resident either has or is at risk for developing.
Which finding from a nursing audit reflects high standards for client safety and institutional health care?
The nurse documents clients' responses to nursing interventions.
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.
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?
Recommendations
A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?
"Clipboards with client data should not leave the unit."
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 think the client would benefit from intravenous furosemide." -R is the last step. R=recommendation
The parents of a hospitalized child ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?
"I will arrange access for you to review the record after you put your request in writing."
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.
-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.
A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines?
Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth
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
What is the primary purpose of the client record?
Communication
According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?
Documentation
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?
Incident report
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?
It provides quick access to abnormal findings
A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?
Problem-Oriented Method
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
Which documentation by the nurse best supports the PIE charting system?
Vomiting 250 mL undigested food, antiemetic given, no further vomiting -PIE charting includes the Problem, Intervention, and Evaluation.
A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and:
reimbursement
To which Health Insurance Portability and Accountability Act regulation should the nurse adhere when safeguarding clients' written, spoken, and electronic information?
submitting a written notice to all clients identifying the uses and disclosures of their health information
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
Which principle should guide the nurse's documentation of entries on the client's health care record?
Precise measurements should be used rather than approximations.
A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?
a client who is homebound and needs skilled nursing care -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 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?
identifying risks and ensuring future safety for clients
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?
Current client assessment