Taylor: Fundamentals of Nursing Chap. 19: Documenting and Reporting

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? "Any information that can identify a person is considered a breach of client privacy." "You may continue to post about a client, as long as you do not use the client's name." "All aspects of clinical practice are confidential and should not be discussed." "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."

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

T/F: Accurate documentation for a patient given Diovan, 10 mg, once daily is: "Diovan, 10 mg, Q.D."

False

T/F: An example of a helpful and accurate nursing note is: "The patient appears to be resting more comfortably today than yesterday."

False

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? Transfer report Telemedicine report Nurse's shift report Incident report

Incident report

PIE

Problem, Intervention, Evaluation

T/F: Critical pathways or care maps, used in the case management model, specify the care plan that is linked to expected outcomes projected along a timeline.

True

T/F: In most facilities, the only circumstance in which orders may be issued verbally is in a medical emergency.

True

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of: - a referral. - reporting. - conferring. - a consultation.

a referral

Quality process review recognizes that _____________ is the primary source of evidence used to continuously measure performance outcomes against predetermined standards.

documentation

Computer-based records, or ____________ health records (EHRs), allow data to be distributed among many caregivers in a standardized format.

electronic

A _______-oriented patient record is one in which each health care group keeps data on its own separate form.

source

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. - identifying demographics, including diagnosis - what time the nurse will return for the next shift - any abnormal occurrences with the client during the shift - current orders

any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current order

source-oriented paper record

each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically, with the most recent entry nearest the front of the record.

Charting by ____________ is a shorthand documentation method in which only deviations from well-defined standards of practice are documented in narrative notes.

exception

The __________________record is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.

graphic

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

identifying risks and ensuring future safety for clients

problem-oriented medical record (POMR)

organized around a patient's problems rather than around sources of information. With POMRs, 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 to identify a master list of patient problems and contributes collaboratively to the plan of care.

SOAP

subjective, objective, assessment, plan

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

"It will allow for us to see the client and possibly increase client participation in care."

T/F: The patient record is the only permanent legal document that details the nurse's interactions with the patient.

True

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? - Create an addendum with a correction. - Contact information technology (IT) staff to make the correction. - Contact the health care provider. - Immediately delete the incorrect documentation.

Create an addendum with a correction.

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A client who resides in Indiana has required hospitalization during a vacation in Hawaii. A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. A client has asked a nurse if he can read the documentation that his physician wrote in his chart. A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer.

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

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

Reporting

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? - narrative charting - PIE charting - FOCUS charting - SOAP charting

SOAP charting