Prep U: Ch 19: Documenting & Reporting

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." explanation: HIPAA has created several changes that protect client confidentiality and affect the workplace. One such change is that the names of clients on charts can no longer be visible to the public, and clipboards must obscure identifiable names of clients and private information about them. Therefore, writing down clinical information, taking the data off the unit, and including client identifiers are inappropriate.

Which is the proper way to document midnight in a client's record?

0000

In SBAR, what does R stand for?

Recommendations explanation: SBAR stands for situation, background, assessment, and recommendations. The other responses are incorrect.

The nursing is caring for a client who requests to see a copy of the client's own 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. explanation: The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the records.

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. explanation: Although the scientific rationale is not documented in the clinical plan, it is no less important than in the instructional plan. Nurses and other members of the healthcare team must know the rationale behind the intervention or must question and review the rationale before performing the action.

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 explanation: Telemedicine and mobile health technology facilitate client engagement, while helping providers deliver more cost-effective care. Telemedicine embraces applications and services that include two-way video communications, e-mail, and wireless phones. Mobile health features multiple technologies integrated into the increasingly wireless and mobile health care delivery system. Client engagement technology would include the concept of client portals (where clients can access an electronic medical record system and personal health information); online appointments scheduling; and personalized, condition-focused alerts/reminders in the form of e-mails, automated telephone calls, or text messages. Data aggregation is a process that involves data collection, analysis, use, reporting, and delivery of feedback throughout the organization. Organizations will use process and outcomes data to measure what they achieve for clients and population-based communities. Population health management technology performs data mining, risk stratification, and analysis. Searches can be conducted for disease trends, diagnoses, procedures, and missed appointments.

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." explanation: The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records. They may also update their health record if inaccurate, get a list of the disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations, request a restriction on certain uses or disclosures, and choose how to receive health information.

The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting." explanation: There are many benefits to electronic charting, though there may be some learning curves involved in knowing how to use electronic formats. It is incorrect to suggest that overtime pay can be earned with end-of-shift charting. Therefore, this statement requires intervention. The other statements are appropriate.

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

2130

An informatics nurse specialist has completed the evaluation of an update to a current clinical information system used by the staff at the local hospital and has documented the results. Documentation reveals the need for an improvement in the screen display. Which action would be next?

Analyze and Plan explanation: Evaluation may be the last phase of the system development lifecycle, but it represents an essential step for nurses to be involved in before circling back to Analyze and Plan based on the results of the evaluation. This step is important to complete before making updates or improvements to a system already in place. Once this step is completed, the other steps of the system development lifecycle would follow.

An informatics nurse specialist is gathering data from electronic health records at the facility about clients who have had central venous catheters inserted for more than the recommended time as specified by the facility's protocol. The nurse specialist is collecting this data most likely for which purpose?

Identify clients at risk for infection explanation: Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. In health care, organizations often use this information to identify clients who may be at risk for problems. This area of health care analytics is not involved with determining client satisfaction, evaluating client care, or correlating the client's diagnosis with interventions.

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. explanation: Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers is an advantage of problem-oriented recording and is therefore correct. Giving clients the right to withhold the release of their information to anyone is a beneficial disclosure and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving clients' problems among caregivers and having numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care are examples of source-oriented recording.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting explanation: Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. .Some facilities may use encrypted (protected) software programs such as Share Point or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.

Which information would the nurse be unable to locate in the client care summary or Kardex?

Respiratory assessment explanation: Information commonly found in a the client care summary or Kardex includes demographic data, code status, safety precautions, basic care needs (such as activity status or diet), and treatment (such as vital sign schedule, IV therapy, and diagnostic or laboratory tests). An assessment would be located on a flow sheet or within the client's medical record.

A health care facility plans to evaluate and revise the plan of care for a client based on the client's health care records. The physician, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details?

SOAP charting explanation: In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. Narrative charting is time-consuming to write and read, as it involves sorting through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

Which organization audits charts regularly?

The Joint Commission explanation: The Joint Commission (TJC)audits client records regularly under specific guiidelines that are announced annually and shared with each institution. TJC also encourages institutions to set up ongoing quality assurance programs. The National League for Nurisng, American Nurses Association, and Sigma Theta Tau International are professional nursing organizations that provide services to nurses; they do not access client records. .

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 explanation: In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem

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." explanation: The client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. The other answers are therefore inappropriate responses.

An informatics nurse is discussing the implementation of a new documentation system with a group of staff nurses who are using the system. Which response by the group would indicate to the nurse that the system's usability is effective? Select all that apply.

"This system fits nicely into how we work." "We've noticed that this system really helps to save us valuable time." "Using the system is highly intuitive." explanation: The National Institute of Standards and Technology defines usability as "the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use" (NIST, 2017). Sometimes the way screens are formatted can be confusing, making it a real challenge to perform nursing tasks in a way that makes sense. Making clinical systems easy to use, intuitive, and supportive of nurses' workflow is what usability is all about. A system with effective usability can save time, reduce errors, and improve end-user satisfaction. A system that makes it challenging to complete tasks or screens that contain large amounts of information do not promote usability.

What is the primary purpose of the client record?

Communication explanation: Patient records serve many purposes., but the ANA states that the most important of these is "communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory and legislative, reimbursement, research, and quality activities" (ANA, 2010, p. 5). Thus communication with the health care team is a more important purpose of documentation than advocacy, research, or education.

An informatics nurse specialist is involved in evaluating a new electronic health record being used by the facility. The nurse specialist will be evaluating the effectiveness of the early warning system for rapid response on reducing the number of codes being called. The nurse specialist has also developed the following question: "Has the new alert system resulted in a reduction in the number of codes being reported?" What would be the nurse specialist's next step?

Complete a literature search of peer-reviewed journals explanation: The informatics nurse specialist has determined what was to be evaluated and developed the appropriate question for evaluation. Next the nurse specialist would conduct a literature search. This would be followed by identifying the data elements to be collected, the appropriate study design, and method of data collection.

According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation explanation: Documentation is the primary source of evidence used to measure performance outcomes, according to the CNA. Accreditation is the process whereby educational institutions are evaluated and, if approved, certified by a third party to validate their compentency. Psychomotor skills are skills that require physical actions and mucular coordination to perform. Clinical judgment is an attribute of health care professionals that involves the use of critical thinking, intuition, and clinical experience when making a decision about a client's care to achieve the best outcome for the client.

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edmatous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"?

FOCUS explanation: The nurse used FOCUS charting, as it gives priority attention to the client's current or changed behavior. PIE charting occurs when the nurse records the client's progress under the headings of problem, intervention, and evaluation. Narrative charting content resembles a log or journal entry. Charting by exception is charting only abnormal assessment findings that deviate from a standard norm. Therefore, this nurse is not demonstrating PIE, narrative, or exception charting.

An informatics nurse is participating in an online continuing education course about nursing informatics. The nurse demonstrates successful comprehension of the course by identifying which individual as being considered the first informatics nurse?

Florence Nightingale explanation: Many have documented that the first informatics nurse was Florence Nightingale, who compiled and processed data to improve sanitation conditions in military hospitals during the Crimean War in the 1850s. Orem, Peplau, and Henderson are nursing theorists.

An informatics nurse is teaching a clinic staff about a newly implemented patient portal being used. The informatics nurse determines that the teaching was effective when the staff identify which aspect as being the focus of this technology?

Greater client engagement explanation: Although improved client outcomes, health promotion and client monitoring may result from the use of patient portals, the primary goal of patient portals is to improve client engagement in their care.

An informatics nurse specialist is recommending the addition of an alert system tool to the facility's patient portal. The tool would be designed to send alerts to the client to schedule routine screenings and immunizations. This recommendation most likely reflects which ANA informatics competency?

Health teaching and health promotion explanation: The alert system tool for screenings and immunizations would reflect the competency of health teaching and health promotion because it would signal the clients about important health promotion activities. The competency of collaboration would be reflected by the nurse specialist partnering with others to conduct nursing and informatics practice with the sharing of data, information, and knowledge about the health care consumer or situation. The competency of quality of practice is reflected by the nurse specialist's contributions to the quality and effectiveness of nursing and informatics practice, as evidenced by quality documentation and data analysis to improve practice and outcomes. The competency of leadership is reflected by the nurse specialist promoting the organization's goals and vision and mentoring colleagues.

Which statement is not true regarding a medication administration record (MAR)?

If the client declines the dose, the nurse does not have to document this on the MAR. explanation: If a client declines a dose, the nurse should circle that dose and write a note as to why the nurse did not administer it. MARs can distinguish between routine and "as needed" medications identify routine times for medication administration. After using an electronic MAR, the nurse should log off to prevent others from inadvertenly adding information about other clients to the initial client's record.

An informatics nurse specialist is evaluating a newly implemented electronic medication alert system for usability. Which area would the nurse evaluate? Select all that apply.

Naturalness Simplicity Consistency explanation: Usability is characterized by the concepts of simplicity, naturalness, and consistency. Interoperability is a separate element that reflects the system's ability to share information across the health care continuum. Improvability is addressed with optimization, which includes strategies for improvement.

An informatics nurse specialist is conducting an orientation for the staff of a primary care provider's office about a new web-based tool that they will be implementing. The goal of the tool is to promote patient engagement. The informatics nurse specialist is most likely orienting the staff to which system?

Patient portal explanation: A primary patient engagement tool is the patient portal, a web-based tool that can be securely accessed and provides several functions to increase engagement. Telehealth is defined as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. Telemedicine involves the use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners. Telecare generally refers to technology that allows consumers to stay safe and independent in their own homes.

A nurse is reading a journal article about health information technology and the need for this technology to demonstrate meaningful use. Which information would the nurse anticipate reading about as reflective of meaningful use? Select all that apply.

Reduction in privacy breaches of client information Greater client engagement Improvement in health care quality explanation: Meaningful use would be reflected by improved quality, safety, efficiency, and reduced health disparities; engagement of clients and family; improved care coordination and population and public health; and maintenance of privacy and security of client health information.

An informatics nurse specialist is preparing a presentation for a local community group about advances in technology in health care. Part of the presentation will focus on technological advances to promote greater client participation in managing health. Which component would the nurse likely describe as playing a major role?

Patient portal explanation: Although the electronic health record and clinical information systems are important technological advances in health care, engaging clients in their care and working together to improve health with supportive technology is an area that continues to advance. A primary client engagement tool is the patient portal. This web-based tool can be securely accessed and provides several functions to increase engagement. Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. It does not involve client engagement.

An informatics nurse is assisting with the design of an clinical information system for use by the staff of a health center. The nurse is working to ensure that the system reflects usability by making sure that the screen display is viusually clean and uncluttered and that it provides only the information needed for decision making. Which concept of usability is the nurse incoroporating?

Simplicity explanation: Simplicity in design refers to everything from lack of visual clutter and concise information display to inclusion of only functionality that is needed to effectively accomplish tasks. A "less is more" philosophy is appropriate, with emphasis being given to information needed for decision making.Naturalness refers to how automatically "familiar" and easy to use (intuitive) the application feels to the user. Consistency involves a pattern. For example, the more users can apply prior experience to a new system, the lower the learning curve, the more effective their usage, and the fewer their errors. Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results. This approach accelerates learning while building in protections against unintended consequences.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions. explanation: Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by The Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health histories and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation.

Which strategy could be implemented by the nurse in ensuring the protection of electronic data at health care agencies?

The nurse locks out client information, except to those who have been authorized through appropriate security measures. explanation: Locking out client information except to those who have been authorized through fingerprints or voice activation is correct. This action enhances confidentiality and protects electronic data in health care agencies. Less frequently changing access numbers and passwords could allow staff who have left the agency to compromise the system. Removing the automatic save and screen saver for data that have been displayed for prolonged periods could allow unscrupulous individuals onto the system. Providing unlimited data access to the multidisciplinary team so personnel from various departments can retrieve the data could allow all staff access to information that does not impact their jobs.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state. explanation: Providing information over the phone to a family member without knowing whether or not the client wants that family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach of confidentiality, but providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator?

Translators may need additional explanations of medical terms. explanation: When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times.

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. explanation: Use abbreviations,but only those that are commonly accepted and approved by the facility. All documentation requires proper grammar and writing techniques. The nurse should be using the particular charting method for the employing institution. All care and observations should be documented - not only changes in a client's status.

An informatics nurse specialist is conducting an in-service education program for a group of staff nurses. The topic is ensuring electronic client data is secure and private. The specialist determines that the teaching was successful when the group identifies which aspect as essential to ensuring the security of electronic data when using clinical systems?

Use of strong passwords explanation: Nurses are responsible for minimizing the risk of harm to clients and providers through both system effectiveness and individual performance. Ensuring secure and appropriate access to clinical systems starts with good management of passwords, including the use of strong passwords. Interoperability and intuitive design are not associated components to ensure secure data. Testing is an important component in the system development lifecycle (SDLC).

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.

any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders explanation: Any identifying information regarding the client's demographics such as name, age, gender, diagnosis, and so on should be communicated to the oncoming nurse caring for the client. Any current orders or orders that have not been completed during the shift should be communicated as well. The oncoming nurse should be informed of any occurrences with the client that have been out of the norm and what actions, if any, were taken. Information about what the client watched for entertainment is not of relevance and should be eliminated from the report, as well as what time the nurse will be working next.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?

subjectivity explanation: Quoting what the client is saying helps in the documentation of subjective data. Objective data are assessment data that may be directly observed by the nurse such as blood pressure. Organization is the structure of the documentation and does not relate to subjective data. Reimbursement is a distractor that doesn't relate to assessment data.