PrepU Chapter 16: Documenting

What is the primary purpose of the client record?

Communication

Which is NOT a purpose of the patient care record?

Contract

Which consultation or referral by the nurse is MOST appropriate for a client who is obese and demonstrates poor wound healing?

Nutritional consult

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 client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis?

Public Health Department

What dual purpose does an audit serve?

Quality assurance and reimbursement

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.

A new graduate is working at a first job. Which statement is MOST appropriate for the new nurse to follow?

Use abbreviations approved by the facility.

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."

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

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

Reporting

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

Urine output 100 mL

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate?

Write a narrative note in the designated nursing section.

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

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."

Meaningful use of technology in client care and management is a goal for everyone involved. The transition from paper to electronic charting generates mixed responses from nurses. Which agency is responsible for monitoring compliance to Health Information Technology for Economic and Clinical Health (HITECH)?

Center for Medicare and Medicaid services

A nurse who 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's record can be more accurante if the nurse:

Uses point-of-care documentation.

A nursing student asks why completing an acuity report is important. What is the BEST response by the nurse?

"It helps determine our staffing requirements."

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 home bound and needs skilled nursing care.

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 nursing instructor is discussing a nursing student's social media post about an interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is MOST appropriate?

"Any information that can identify a person is considered a breach of client privacy."

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mm Hg when all other vital signs are normal. This reflects what type of documentation?

Charting by exception

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

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

Interpretation of data

The nurse in making an entry on the client's charted "Medicated with meperidine 50 mg at midnight." How would the nurse document the entry using military time?

0000

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.

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

A flow sheet

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

Legal document

A nurse is working as a case manager and audits charts. Audits of client records are performed for quality assurance and:

Reimbursement

The nurse hears an 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?

Remind the UAP about the client's right to privacy.

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

Documentation

Which abbreviation is correct for use in documentation?

PO

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.

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 report at the bedside. Which response by the nurse receiving 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."

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

1 Unit of glucose

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the BEST defense against allegations of negligence?

Accurately documenting client care on the client record.

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. What action by the nurse is MOST appropriate?

Ask the client if information can be given to the parent.

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.

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. What response by the nurse is MOST appropriate?

Explain the reason why information cannot be disclosed.

Which charting formats permit documentation on any significant topic, not just client problems?

FOCUS

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 ambulated 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.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting client's response to nursing interventions.

A nurse documents the following client data in the patient 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

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

The nurse documents clients' responses to nursing interventions.

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.

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 refuses. The nurse's refusal is based on the understanding that which people would be entitled to access of the client's records?

Those directly involved in the client care.

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?

Inform the health care provider that a written order is needed.

What does the nurse recognize as purposes of the electronic health record? Select all that apply.

Documenting continuity of care Qualifying healthcare providers for government funds. Ensuring client safety. Facilitating health education and research.

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 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