Prep U's - Chapter 19 - Documenting and Reporting

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? A. Inform the health care provider that a written order is needed. B. Call the pharmacy to have the order entered in the electronic record. C. Write the order in the client's record. D. Add the new order to the medication administration record.

Answer: A Rationale: Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.

In SBAR, what does R stand for? A. Recommendations B. Reinforcing data C. Response D. Report

Answer: A Rationale: SBAR stands for situation, background, assessment, and recommendations. The other responses are incorrect.

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? A. Care plan and client's record B. Client's record and occurrence report C. Occurrence report and critical pathway D. Critical pathway and care plan

Answer: B Rationale: An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? A. Dialogue B. Verification C. Documentation D. Reporting

Answer: D Rationale: 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.

What ensures continuity of care? A. communication B. reassessment C. integration D. critical thinking

Answer: A Rationale: Communication ensures continuity of care and provides essential data for revision of. or continuation of care. The acts of reassessment, critical thinking, and integration do not contribute directly to continuity of care.

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records? A. "The clients' medical records are an obstruction to research and education." B. "The clients' health records should be used to promote reimbursement from insurance companies" C. "I can share the clients' medical records with the health care team." D. "The clients' medical records provide data for legal evidence."

Answer: A Rationale: The clients' medical records are good sources of data for research and education, and, therefore, it is incorrect to say that they are an obstruction. The other statements do not need correction.

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? A. PIE B. MAR C. SOAP D. SBAR

Answer: D Rationale: The nurse should use SBAR (situation, background, assessment, recommendation) when communicating with the health care provider. SOAP and PIE are nursing notes in the medical record, and MAR is medication administration record.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: A. factual statement. B. important information. C. relevant data. D. interpretation of data.

Answer: D Rationale: A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today.

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? A. The client appears comfortable and is resting adequately and appears to not be in acute distress. B. The client is receiving sufficient relief from pain medication, stating no pain in either knee. C. The client appears to have a low tolerance for pain and frequently reports intense pain. D. The client reports that on a scale of 0 to 10, the current pain is a 3.

Answer: D Rationale: The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? A. PIE B. SBAR C. MAR D. SOAP

Answer: B Rationale: The nurse should use SBAR (situation, background, assessment, recommendation) when communicating with the health care provider. SOAP and PIE are nursing notes in the medical record, and MAR is medication administration record.

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? A. The client is receiving sufficient relief from pain medication, stating no pain in either knee. B. The client appears to have a low tolerance for pain and frequently reports intense pain. C. The client appears comfortable and is resting adequately and appears to not be in acute distress. D. The client reports that on a scale of 0 to 10, the current pain is a 3.

Answer: D Rationale: The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? A. subjectivity B. objectivity C. reimbursement D. organization

Answer: A Rationale: 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.

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? A. 1 Unit of glucose B. 1 bottle of glucose C. One U of glucose D. 1U of glucose

Answer: A Rationale: The nurse should write "1 Unit of glucose." The nurse cannot write "1 bottle" or "one U of glucose" because these are not the accepted standards. "1U" is an abbreviation that appears in the JCAHO "Do Not Use" list (see http://www.jcaho.com). It should be written as "1 Unit" instead of "1U" because "U" is sometimes misinterpreted as "zero" or "number 4" or "cc."

A nurse is transfusing multiple units of packed red blood cells. 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? A. "I think the client would benefit from intravenous furosemide." B. "This client has a medical history of heart failure." C. "I am calling because the client receiving blood has developed dyspnea and had crackles." D. "It seems like this client has fluid volume overload."

Answer: A Rationale: Situation, background, assessment, and recommendations (SBAR) provides a consistent method for hand-off communication that is clear, structured, and easy to use. The S (situation) and B (background) provide objective data, whereas the A (assessment) and R (recommendations) allow for presentation of subjective information. Calling to report dyspnea and crackles occurs as the nurse describes the situation. Providing the medical history occurs as the nurse offers important background information. Stating that the client has fluid volume overload is the assessment of the nurse. Stating that the nurse thinks the client would benefit from intravenous furosemide is the nurse's recommendation.

A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse likely document the results? A. admission nursing assessment B. progress notes C. medical record D. graphic sheet

Answer: D Rationale: The graphic sheet 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. The purpose of progress notes is to inform caregivers of the progress a client is making toward achieving expected outcomes. The medical record is a general term for all of the client's medical information, which would include progress notes, flow sheet, and graphic sheets, to name a few.The admission nursing assessment records the findings of the nursing history and physical assessment upon admission.

The nurse is taking verbal medication prescriptions from the provider by hand to be documented in the clients eMAR for administration of medication. How should the nurse correctly document this information? A. 1200-Tramadol 50mg PO with OJ for pain rated 6 out of 10. Jane Doe RN. B. Celecoxib 100 mg @ 0800 with applesauce, Jane Doe RN. C. Sertraline 100 mg per os HS 20:00. JD, RN. D. 0800-Amoxicillin 250mg PO with water. J. Doe, RN.

Answer: D Rationale: When documenting information in a client's health care record, the nurse should sign each entry by name, first initial and last name, and title. Correct documentation also includes recognition of those abbreviations and terms on the "Do Not Use" list such as "per os" and "OJ" which can be confused with other terminology meanings. Time stamps should also be included in documentation.

Which note includes all elements of a SOAP note? A. Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness. B. Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. C. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess. D. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis.

Answer: A Rationale: A SOAP note consists of subjective information, objective information, an assessment, and a plan. The correct response includes each of these while the remaining three responses are each lacking a different one of the components.

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? A. "It will allow for us to see the client and possibly increase client participation in care." B. "It makes our client feel like we care, especially if we start the day off with a clean room." C. "It will let me see everything that has been done and things that need to be done." D. "It will give me a better sense of what my workload will be today."

Answer: A Rationale: Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

Which is not a purpose of the client care record? A. To serve as a contract with the client. B. To assist with care planning. C. To serve as a legal document. D. To facilitate reimbursement.

Answer: A Rationale: Client care records are legal documents, communication tools, and assessment tools. They are used for care planning, quality assurance, reimbursement, research, and education. They in no manner reflect a contract between health care staff and the client. The only exception to this is at the point of admission when the client (or responsible party) signs an acknowledgement of expenses about to be incurred as health care insurance information is obtained.

Which finding from a nursing audit reflects high standards for client safety and institutional health care? A. The nurse documents clients' responses to nursing interventions. B. The nurse records inappropriate nursing interventions. C. The nurse fails to adequately complete data on clients' health histories and discharge planning. D. The nurse fails to identify the nursing diagnoses or clients' needs.

Answer: A Rationale: 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.

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? A. progress notes B. problem list C. data base D. plan of care

Answer: A Rationale: 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.

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? A. identifying risks and ensuring future safety for clients. B. following up the incident with other members of the care team. C. protecting the nurse and the hospital from litigation. D. gauging the nurse's professional performance over time.

Answer: A Rationale: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team.

Which principle should guide the nurse's documentation of entries on the client's health care record? A. Precise measurements should be used rather than approximations. B. Nurses should not refer to the names of health care providers. C. Correcting fluid is used rather than erasing errors. D. Documentation does not include photographs.

Answer: A Rationale: Precise measurements and times must be used whenever possible. It is appropriate to use the names of health care providers and photographs can constitute documentation. Handwritten entries should be struck through with a single line and initialed, not covered with correcting fluid or erased.

The nurse is caring for a client who has been physically restrained. Which observation(s) will the nurse include when documenting the client's care? Select all that apply. A. The client's blood pressure is 135/82 mm Hg. B. The client participates in range-of-motion exercises. C. The client exhibits agitation and shouts at the nurse. D. The client's skin turgor is normal. E. The client has redness around the ankles bilaterally.

Answer: A, B, C, D, E Rationale: Agencies have varying protocols for client care and documentation when a client has been physically restrained. The nurse is responsible for following agency protocols and practicing within the minimum requirements of the nursing scope to ensure the client's safety and document care accurately. The client's chart must contain documented evidence of frequent and regular nursing assessments of the restrained client's vital signs, circulation, skin condition or signs of injury, psychological status and comfort, and readiness for discontinuing restraint. In addition, the nurse must record nursing care concerning toileting, nutrition, hydration, and range of motion while the client is restrained.

The nurse is caring for a postoperative client who is experiencing hypotension. When contacting the client's health care provider, the nurse will include which statement in the SBAR report? Select all that apply. A. "The client has had a sudden drop in blood pressure from 125/90 down to 90/60 mm Hg." B. "The client was just admitted to this unit from post anesthesia recovery after having abdominal surgery." C. "The client is very distressed. I am very concerned about how the client is coping right now." D. "The client demonstrates additional signs of hypovolemia including slow capillary refill." E. "I have diagnosed the client with an internal bleed and need orders to treat accordingly."

Answer: A, B, D Rationale: When notifying the health care provider about a change in a client's condition, the nurse documents in the client's record the information reported, and the instructions received. In an effort to improve client safety by improving staff communication and identifying client safety risks, the SBAR format has been recommended as a model for effective communication. SBAR refers to S (Situation): What is the situation about which you are calling, B (Background): Pertinent background information related to the situation, A (Assessment): What is your assessment of the situation? R (Recommendation): Explain what is needed or wanted. The SBAR does not require the nurse to formulate a medical diagnosis. It is not within the nurse's scope to conclude that the client has an internal bleed, instead, the nurse would make a recommendation for what is needed, for example, for the health care provider to attend the client and assess further. While it is important to respond to the client's needs, if they are distressed, the nurse will not include this information in the SBAR because it does not focus on the issue that needs to be immediately prioritized which is the sudden hypotension.

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? A. It documents assessments on separate forms. B. It provides quick access to abnormal findings. C. It provides and refers to a client's problem by a number. D. It records progress under problems, intervention, and evaluation.

Answer: B Rationale: Charting by exception (CBE) provides quick access to abnormal findings, as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse? A. "The hospital owns your records and does not have to allow you access while you are a client here." B. "I will have to review the policy that determines what procedure is in place for client access." C. "You may not understand all of the information and it will confuse you so I will help you decipher it all." D. "Let me open up the computer access so that you can see what information is of interest to you."

Answer: B Rationale: Clients have the right to see their own medical records and request changes to documentation that may be in error. Most facilities have a policy in place for the client to obtain medical records and the nurse should ensure that the policy is followed by being familiar with that policy prior to giving the client free access to the record. The nurse should not demean the client by assuming that the information may be confusing. The nurse should not allow the client access to the computer while using the nurse's password or login information. While the hospital maintains responsibility for the record, the client has the right to see it.

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? A. "The CABG procedure will help increase intestinal motility and prevent constipation." B. "A coronary artery bypass graft will benefit your heart." C. "The CABG procedure will help identify nutritional needs." D. "A complete ablation of the biliary growth will decrease liver inflammation."

Answer: B Rationale: Coronary artery bypass graft is abbreviated CABG. It does not identify nutritional needs, decrease liver inflammation, or increase intestinal motility.

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? A. Problem-oriented recording has 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. B. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. C. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. D. Problem-oriented recording gives clients the right to withhold the release of their information to anyone.

Answer: B Rationale: 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 providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? A. The nurse can implement care once written orders are received from the provider. B. The nurse can accept verbal orders to provide immediate care and record once the client is stable. C. The provider can input orders remotely into the EHR system for the nurse to retrieve. D. The client must be stabilized before the nurse can obtain any orders from the provider.

Answer: B Rationale: In most agencies, the only circumstance in which the attending health care provider, nurse practitioner, or house office may issue orders verbally is in a medical emergency. In such a situation, the health care provider/nurse practitioner is present but finds it impossible to write the order due to the emergency circumstances. When a client is admitted to the unit, the prescriber writes orders either in the electronic record or on paper. Health care provider can insert orders remotely, but this is not the most appropriate option in an emergency. Stabilization of the client, while important, should not supersede receiving orders as the providers instructions could be integral to stabilizing the client.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? A. Documenting clients' health histories and discharge planning. B. Omitting clients' responses to nursing interventions. C. Recording nursing interventions. D. Identifying nursing diagnoses or clients' needs.

Answer: B Rationale: Omitting clients' responses to nursing interventions is correct because it does not fit the criteria for legally defensible charting. Recording nursing interventions, identifying nursing diagnoses or client needs, and documenting clients' health histories and discharge planning are all criteria for legally defensible charting and would demonstrate evidence of quality care.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? A. health care professionals of the facility B. those directly involved in the client's care. C. any family member of the client D. close friends of the client

Answer: B Rationale: Only those directly involved in client care are entitled to access the client's information. Family members and close friends do not have access to the client's records, as per the privacy policy applicable to each client. Health care professionals of the health care facility may not access client information unless involved in that client's care at that time.

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? A. Talking directly to the translator facilitates the transfer of information. B. Translators may need additional explanations of medical terms. C. It is always okay to not use a translator if a family member can do it. D. Talking loudly helps the translator and the client understand the information better.

Answer: B Rationale: 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.

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. A. what time the nurse will return for the next shift. B. current orders C. identifying demographics, including diagnosis. D. what the client watched on television during the shift. E. any abnormal occurrences with the client during the shift.

Answer: B, C, E Rationale: 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.

A nurse manager of a health care provider's office is responsible for obtaining signed authorizations for releasing client information to third parties. In which situations would it not be necessary for the nurse to obtain an authorization from the client? Select all that apply. A. Sharing information regarding home care with a client's spouse B. Releasing a medical record to the court when a nurse is being sued for negligence. C. Submitting charges for nursing services. D. Reporting the incidence of an infectious disease to Centers for Disease Control and Prevention. E. Providing statistics related to the use of a dangerous piece of equipment. F. Facilitating organ donation of a deceased client.

Answer: B, D, E, F Rationale: According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 Authorization Rule, the following options would not need an authorization: releasing information to the Centers for Disease Control and Prevention regarding an infectious disease; releasing a medical record to the court when a nurse is being sued for negligence; facilitating organ donation of a deceased client; and providing statistics related to the use of a dangerous piece of equipment. The nurse would need authorization from the client to share information regarding home care with a client's spouse and submitting charges for nursing services.

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? A. Nurse's shift report B. Transfer report C. Incident report D. Telemedicine report

Answer: C Rationale: An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? A. "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family." B. "You may continue to post about a client, as long as you do not use the client's name." C. "Any information that can identify a person is considered a breach of client privacy." D. "All aspects of clinical practice are confidential and should not be discussed."

Answer: C Rationale: Any information that can identify a person is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the facility and unit is disclosed in the post. Discussion of clinical practice can be helpful for learning purposes or seeking advice on care. No care should be discussed, even privately, with friends and family without first obtaining the client's permission.

Which is the primary purpose of client records? A. Performance improvement B. Reimbursement C. Communication D. Legal protection

Answer: C Rationale: Client records serve many purposes. The primary purpose of the client record is to help health care professionals from different disciplines (who interact with the client at different times) communicate with one another. Communication fosters continuity of care. The ANA states that the most important purpose of client records 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."

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? A. Problem-oriented recording has 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. B. Problem-oriented recording gives clients the right to withhold the release of their information to anyone. C. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. D. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers.

Answer: C Rationale: 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.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? A. a client whose status is stabilized. B. a client who is not making progress in expected outcomes of care. C. a client who is homebound and needs skilled nursing care. D. a client whose rehabilitation potential is not good.

Answer: C Rationale: 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.

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error? A. Immediately delete the incorrect documentation. B. Contact the health care provider. C. Create an addendum with a correction. D. Contact information technology (IT) staff to make the correction.

Answer: C Rationale: If the nurse is using an EMR and the documentation cannot be changed, an addendum will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies. The health care provider does not need to be contacted to make a correction, but does need to be informed if this caused any direct harm or effects to the client.

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information? A. Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. B. Client states expecting some pain, but it is more severe than anticipated. C. Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." D. Client is requesting pain medications, is grimacing, and is diaphoretic.

Answer: C Rationale: In the SOAP format, "S" refers to subjective data, which are usually recorded as the client's statement, or anything verbalized by the client. The statement about pain secondary to postoperative status and increased activity reflect the "A," or assessment, portion of the SOAP format. The statements about the abdomen being soft, bowel sounds, and so on reflect the "O," or objective data, portion of the SOAP format. The statement about physical manifestations of pain is not subjective data.

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? A. The abdominal area B. Lung sounds C. The lower extremities D. Heart rate and rhythm

Answer: C Rationale: Peripheral vascular disease mostly affects the lower extremities. While the lung sounds, heart rate and rhythm, and abdominal assessment will be important, the focused assessment should be on the lower extremities.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? A. Dialogue B. Verification C. Reporting D. Documentation

Answer: C Rationale: 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 nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? A. "I am calling about the client in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." B. "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." C. "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." D. "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."

Answer: C Rationale: SBAR refers to: S (situation): what is the situation you are calling about?; B (background): pertinent background information related to the situation; A (assessment): what is your assessment of the situation?; R (recommendation): explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? A. The plan includes interventions, evaluation, and response. B. Abnormal laboratory values are common items that are documented. C. Subjective data should be included when documenting. D. Objective data are what the client states about the problem.

Answer: C Rationale: Subjective data should be included when using the SOAP format for documentation. Objective data are what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care provider's judgment of the situation, and abnormal lab values would be included in objective data.

Which organization audits charts regularly? A. National League for Nursing B. Sigma Theta Tau International C. The Joint Commission D. American Nurses Association

Answer: C Rationale: The Joint Commission (TJC)audits client records regularly under specific guidelines that are announced annually and shared with each institution. TJC also encourages institutions to set up ongoing quality assurance programs. The National League for Nursing, American Nurses Association, and Sigma Theta Tau International are professional nursing organizations that provide services to nurses; they do not access client 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? A. PIE charting B. narrative charting C. SOAP charting D. FOCUS charting

Answer: C Rationale: The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. 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. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort 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.

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? A. Focus charting method B. PIE charting method C. Problem-oriented method D. Source-oriented method

Answer: C Rationale: The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care. Progress notes clearly focus on client problems. Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, health care providers, laboratory, x-ray personnel, and so on. Notations are entered chronologically. PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). Focus charting method brings the focus of care back to the client and the client's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a client and client care.

A nurse is documenting care for an older adult client who is recovering from a mild stroke. Which documentation entry(ies) follows the recommended guidelines for communicating and documenting client information? Select all that apply. A. The client appears anxious about having another stroke. B. Vital signs returned to normal. C. Radial pulse 72 beats/min, strong and regular. D. The client rates pain as 2 compared to a 7 yesterday. E. The client seems comfortable today. F. The client drank an average amount of fluids.

Answer: C, D Rationale: Documentation that the nurse records should be objective. The client using the pain rating scale and recording the actual pulse and information about the pulse would be correct. Subjective terms must be avoided in the nurse's objective documentation. The nurse would not document that the client seems "comfortable," drank an "average" amount of fluids, has "normal" vital signs, or appears "anxious." Each of these terms means different things to different people. The nurse should take the time to chart this information objectively.

Which are appropriate actions for protecting clients' identities? Select all that apply. A. Ensure that clients' names on charts are visible to the public. B. Orient computer screens toward the public view. C. Have conversations about clients in private places where they cannot be overheard. D. Place light boxes for examining X-rays with the client's name in private areas. E. Document all personnel who have accessed a client's record.

Answer: C, D, E Rationale: Documenting all personnel who have accessed a client's record, placing light boxes for examining X-rays with the client's name in private areas, and having conversations about clients take place in private where they cannot be overheard are useful strategies to limit casual access to the identity of clients and health informatics. Orienting computer screens toward the public view and visibly displaying clients' names on charts are incorrect, as these are breaches of client confidentiality.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. A. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards. B. Making the names of clients on charts visible to the public. C. Keeping record of people who have access to clients' records. D. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public. E. Obscuring identifiable names of clients and private information about clients on clipboards

Answer: C, D, E Rationale: Obscuring identifiable names of clients and private information about clients on clipboards; placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public; and keeping record of people who have access to clients' records are required under the Health Insurance Portability and Accountability Act (HIPAA), which is legislation that attempts to limit casual access to the identity of clients. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards and making the names of clients on charts visible to the public are violations of HIPAA, as these activities allow casual access to the identity of clients.

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? A. The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. B. The nurse sends or directs someone to take action in a specific nursing care problem. C. The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. D. The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

Answer: D Rationale: A nursing care conference is a meeting of nurses to discuss some aspect of a client's care.

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the health care provider's information in the health care provider's progress notes. The nurse is using which method of documentation? A. PIE charting B. Charting by exception C. Problem-oriented D. Source-oriented

Answer: D Rationale: A source-oriented record is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, health care providers, laboratory, x-ray personnel, and so on. Notations are entered chronologically, with the most recent entry being nearest the front of the record. Problem-oriented medical record (POMR) or problem-oriented record is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. PIE charting system is unique in that it does not develop a separate care plan. The care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified). In this documentation system, a client assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms (flow sheets). Client problems identified in these assessments are numbered, documented in the progress notes, worked up using the problem, intervention, evaluation (PIE) format, and evaluated each shift. 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 narrative notes.

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: A. The rationale is deleted to provide additional charting space in the computer system. B. Rationales are only important while the nurse is in training. C. The use of rationales is not commonly practiced in the clinical setting. D. Although not written, the nurse must know or question the rationale before performing an action. E. Some facilities do not require them on their plans of care.

Answer: D Rationale: 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.

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse? A. "Are you questioning the care of your child?" B. "No, the health care provider will not give you access to review the records." C. "Only the client has the right to review the health care records." D. "I will arrange access for you to review the record after you put your request in writing."

Answer: D Rationale: Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. Because the child is a minor, it is the parents' right to view the client's record. Therefore, the statements about the health care provider not giving the parents access to review the records and asking if the parents are questioning the care of their child are incorrect.

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? A. "It will let me see everything that has been done and things that need to be done." B. "It will give me a better sense of what my workload will be today." C. "It makes our client feel like we care, especially if we start the day off with a clean room." D. "It will allow for us to see the client and possibly increase client participation in care."

Answer: D Rationale: Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

Which statement is not true regarding a medication administration record (MAR)? A. The MAR identifies routine times for medication administration. B. The MAR distinguishes between routine and "as needed" medications. C. After using an electronic MAR, the nurse should log off. D. If the client declines the dose, the nurse does not have to document this on the MAR.

Answer: D Rationale: 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 inadvertently adding information about other clients to the initial client's record.

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? A. plan of care B. problem list C. data base D. progress notes

Answer: D Rationale: 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 explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate? A. "CBE is a relatively new format of documentation in electronic health records." B. "CBE is the best way to protect against lawsuits." C. "The benefit of CBE is that it demonstrates whether high-quality care is given." D. "The benefit of CBE is less time needed on computer charting."

Answer: D Rationale: One of the benefits of CBE is less time needed for documentation. CBE does not always support high-quality care and is not the best way to protect against lawsuits since not all data are documented. CBE is not a new format for documentation.

The nurse hears unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? A. Notify the client relations department about the breach of privacy. B. Document the UAP's conversation. C. Report the UAP to the nurse manager. D. Remind the UAP about the client's right to privacy.

Answer: D Rationale: The nurse should first remind the UAP about the client's right to privacy. All other actions are appropriate, but do not immediately protect the client's privacy.