Professional Nursing: Documentation

A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information?

"I can take a telephone prescription if a provider is directing a code for an unresponsive client." Rationale: Telephone prescriptions should be reserved for use only in emergency situations, because there is a risk for misunderstanding details about the prescription during verbal communication. An unresponsive client is an emergency, so it is appropriate for a nurse to receive a telephone prescription in this situation.

A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include?

"Personnel can be terminated for breaching a client's confidentiality" Rationale: The nurse should plan to inform the group that strong penalties exist for HIPAA violations, which include breaching client confidentiality. Penalties include termination from the facility, imprisonment, loss of professional licensure, or fines.

A nurse is reviewing the documentation of a newly licensed nurse. Which of the entries should the nurse identify as meeting the American Nurses Association (ANA) standards of documentation?

"The client vomited 240 mL of clear emesis but denies pain or nausea" Rationale: According to ANA standards, documentation should be factual and complete. Information charted here includes measurements, visual observations, and client data.

A nurse is reviewing documentation principals with a group of newly hired assistive personnel (AP). Which of the following should the nurse include?

A nurse who delegates a task to an AP will review the charting for that task Rationale: Registered nurses (RNs) and licensed practical nurses (LPNs) have authority to delegate certain tasks in certain situations. Part of delegation includes following up to ensure that the task was documented correctly in the client's record.

A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include?

A problem-oriented medical record uses progress notes, which promotes information sharing among members of the interdisciplinary team. Rationale: A problem-oriented medical record uses progress notes, which promotes information sharing among members of the interdisciplinary team.

A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication?

By mouth Rationale: The nurse should identify that "PO" is the abbreviation for "by mouth." It is included in the list of common medical abbreviations. The nurse should plan to administer the morphine by mouth.

A charge nurse is reviewing soap documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data?

Rebound tenderness noted in RLQ of the abdomen Rationale: Objective data is information the nurse gathers when collecting data about the client, such as through physical assessment or diagnostic testing.

A nurse is discussing computerized provider order entry systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE system?

CPOE systems can increase the speed of care delivery Rationale: CPOE systems allow provider prescriptions to be transmitted more quickly from one department to another, which can increase the speed of care delivery for clients.

A newly licensed nurse is orienting to a facilities documentation process. The facility requires staff to on,y document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods?

Charting by exception Rationale: With charting by exception (CBE), health care professionals only chart unexpected findings. This can be done on a flowsheet or through narrative notes.

A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include?

Facilities can establish their own rules for documentation methods Rationale: The nurse should inform the AP that each facility can establish rules for documentation and use of medical records.

A nurse is talking with a client about the electronic health record at the facility. Which of the following client statements indicates an understanding of EHRs?

I will be able to track my health information Rationale: The nurse should recognize that one benefit of EHRs is that clients are able to access their health information from various encounters with health care providers.

A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record?

Immunization data Rationale: The nurse should include that a health record contains any information that could influence a client's health, such as immunization status. Other information includes medications, allergies, and demographic data.

A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on the joint commissions do not use list?

MSO4 This abbreviation for morphine appears on The Joint Commission's Do Not Use list because it can be mistaken for magnesium sulfate. The medication should be written out as "morphine sulfate." IU This abbreviation for international units appears on The Joint Commission's Do Not Use list because it can be mistaken for IV or the number 10. The word "unit" should be written out in full. qhs This abbreviation for "every night" appears on The Joint Commission's Do Not Use list because it can be mistaken for qhr, or "every hour." The abbreviation should be written out as "nightly."

A nurse in the clinic is reviewing a clients prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed?

PRN Rationale: PRN is the abbreviation for "as needed." It is included in the list of commonly used medical abbreviations. The nurse should ensure the client understands other instructions for PRN administration, such as the frequency or the reason the medication should be taken.

A charge nurse is reviewing characteristics of electronic documentation with staff at a providers office. Which of the following characteristics should the charge nurse plan to include?

Reduces medical errors The charge nurse should inform the staff that electronic documentation systems can help reduce medical errors. Makes client medical history more easily available The charge nurse should include that electronic records help to make client information readily available to health care professionals. Increases accuracy of coding procedures The charge nurse should inform the staff that electronic records can lead to more reliable coding and billing for client conditions.

A nurse manager is reviewing the documentation of for newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly?

Synthroid 100 mg PO every morning ac Rationale: This medication entry is written correctly because both PO and ac are commonly used abbreviations and do not appear on The Joint Commission's Do Not Use list.

A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs.

The Institute of Medicine (IoM) Rationale: The Institute of Medicine MY ANSWER The nurse should identify that the Institute of Medicine is the agency that recommended nationwide use of EHRs in 1997. The recommendation was driven by the belief that it would increase safety in client health care.

A nurse is documenting information in a clients chart and makes the entry quotation mark client reports "abdominal pain on exertion". Which of the following documentation format describes this entry?

The S in soap Rationale: The "S" in the acronym SOAP represents "subjective." This documentation entry by the nurse contains information from the client about their feelings of pain.

A nurse is caring for a client after a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first?

The admitting provider The nurse should identify that health care professionals who are directly involved in the client's care, such as admitting or consulting providers, are allowed access to the client's records. The charge nurse on the unit The nurse should identify that health care professionals who are directly involved in the client's care, such as those who supervise client care (charge nurse, nursing supervisor), are allowed access to the client's records. The client The nurse should recognize that the client has the right to view their own medical record at any time.

A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following should the nurse include as a benefit of electronic documentation?

The system alerts providers of possible actions that could cause client harm Rationale: Many electronic documentation systems contain clinical alerts, which can prompt providers regarding potential errors, such as a medication error or duplicate tests.