NUR313 Ch 10 Healthcare Team Communication: Documenting and Reporting

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 has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose

TeamSTEPPS® includes strategies

(e.g., SBAR) to improve how communication occurs in the healthcare system.

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

source-oriented record is a

paper format in which each health care group keeps data on its own separate form

serious reportable events (SRE) (National Quality Forum, 2007),

popularly known as "never events."

Which is true of collaborative pathways?

Are also called critical pathways or care maps

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.

Charting by exception (CBE) is

a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in the narrative notes. Charting by exception decreases charting time.

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

flow sheet

The SOAP format organizes information into

subjective (S), objective (O), assessment (A), and plan (P) categories. - Chronologic narrative nursing progress notes may be difficult to follow when checking the progress of the patient on a specific problem

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.

SBAR

S: Situation B: Background A: Assessment R: Recommendation

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 referral.

An audit is

a review of records. Audits of patient records serve a dual purpose: quality assurance and reimbursement. Auditing is done for quality assurance when records are randomly selected to determine whether certain standards of care were met and documented

The purposes of the patient record are

communication, assessment, care planning, education, research, auditing, and legal documentation.

Principles of documentation include

confidentiality accuracy, completeness, conciseness, objectivity, organization, timeliness, and legibility.

The PIE format incorporates the plan of care into

the progress notes. Information is organized according to problem (P), intervention (I), and evaluation (E).

FOCUS charting does not

use a problem list of nursing or medical diagnoses, but incorporates many aspects of the client and client care into a FOCUS column.