TEST 4: Chapter 26 Mastering (Fundamentals of Nursing)
A group of nurses are discussing the advantages of using computerized provider order entry (CPOE). Which statements indicate that the nurses understand the major advantage of using CPOE?
*A. "CPOE reduces transcription errors." B. "CPOE reduces the time necessary for healthcare providers to write orders." C. "Healthcare providers can write orders from any computer that has Internet access." D. "CPOE reduces the time nurses use to communicate with healthcare providers." RATIONALE: CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly; therefore, CPOE reduces transcription errors. CPOE does not necessarily reduce the amount of time it would take a healthcare provider to write a safe and accurate order. CPOE should not decrease communication within the interprofessional team. Orders should only be written on secure networks to ensure patient privacy.
The nurse is given a form with preset standard findings for recording a progress note. The nurse reports the findings in the following way: "Physical Exam: All systems within normal except left lower extremity, casted d/t to heel fracture. Review of Systems: All normal except pain in the left foot." What kind of documentation and informatics is this?
*A. Charting by exception B. DAR (data, action of nursing intervention, and response of the patient) report C. PIE (problem, intervention, and evaluation) report D. Narrative report RATIONALE: Charting by exception uses forms that have predefined normal findings. The nurse only documents findings that not standard. Unless documented, all other findings are assumed to be normal. Charting is recording or updating a patient's chart. The DAR report consists of an elaborate description of the patient's concerns, signs and symptoms, condition, nursing diagnosis, behavior, significant events, or change in a patient's condition. The PIE report documents problem—intervention—an evaluation and is not narrative. A narrative report is documentation of information in a narrative format.
Using the SOAP format, which represents the appropriate P statement?
*A. Reposition the patient on the right side. Encourage the patient to use the patient-controlled analgesia (PCA) device. B. The patient states, "The pain increases every time I try to turn on my left side." C. Acute pain is related to tissue injury from a surgical incision. D. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. RATIONALE: The planning statement is, "Reposition the patient on the right side. Encourage the patient to use the patient-controlled analgesia (PCA) device." The subjective statement is the patient's statement, "The pain increases every time I try to turn on my left side." The objective statement is, "Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation." The assessment statement is, "Acute pain is related to tissue injury from surgical incision." STUDY TIP: Be sure to understand the meanings of each letter of SOAP and understand what types of information go into each section.
You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which pieces of information do you include in the report? Select all that apply.
*A. The patient's name, age, and admitting diagnosis *B. Allergies to food and medications C. Your evaluation that the patient is "needy" D. How much the patient ate for breakfast *E. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of acetaminophen RATIONALE: During change of shift report, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include the response to treatments such as the response to pain-relieving measures. Information about how much the patient ate for breakfast is not necessary. This information is in the chart if the nurse really needs to know. Do not include critical comments about your patients.
A registered nurse is teaching a group of student nurses about the nursing process in a hospital. Which statement made by a student nurse indicates the need for additional teaching?
A. "Focus charting follows a data, action, and response (DAR) format." B. "SOAP originated from medical records and PIE charting has a nursing origin." *C. "The subjective and objective data are included in problem, intervention, evaluation (PIE) charting." D. "The patient's verbalizations are included under subjective data in the subjective, objective, assessment, plan (SOAP) format." RATIONALE: An assessment process that includes subjective and objective data is not included in the PIE charting format. PIE charting includes only the problem, the necessary intervention, and an effective outcome. Focus charting follows a data, action, and response (DAR) format. This format reflects various steps of the nursing process. SOAP and PIE charting are similar in their problem-oriented nature. However, the SOAP format originated from the medical records and PIE charting has a nursing origin. The verbalizations of the patient are included under the subjective data in the SOAP format. TEST-TAKING TIP: Read the question carefully before looking at the answers: (1) Determine what the question is really asking and look for key words, (2) Read each answer thoroughly and see if it completely covers the material asked by the question, and (3) Narrow the choices by immediately eliminating answers you know are incorrect.
A registered nurse is teaching a group of student nurses about legal guidelines for the effective recording of a patient's data on a handwritten paper document. Which statement by a student nurse needs correction?
A. "I should avoid using generalized, empty phrases." B. "I should put a line through errors made while recording." C. "I should record all written entries legibly and in black ink." *D. "I should leave spaces with unknown information blank." RATIONALE: The nurse should not leave blank spaces while recording the patient's health information, because another person may add incorrect information in the blank spaces. The nurse should draw a horizontal line in the space with his or her signature at the end to avoid this potential issue. The nurse should avoid using generalized, empty phrases such as "had a good day," which do not provide any information. Errors should not be erased, because doing so may indicate that the nurse is hiding some evidence. Errors should be scratched out with a single line, and the nurse should sign and date it. Black ink is more legible when records are photocopied or scanned, and illegible entries may lead to misinterpretations. TEST-TAKING TIP: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
How is proper documentation of a patient's health information useful to medical insurance companies? Choose the best answer.
A. It helps in providing preventive care to the patients. *B. It helps in determining the diagnosis-related group (DRG) of the patient. C. It helps in reducing the cost of the monthly premium paid by the patient. D. It helps in reducing the cost of healthcare services provided to the patient RATIONALE: In order to determine healthcare reimbursements that have to be provided for the patient, insurance companies have to first determine the diagnosis-related group (DRG) of the patient. This can be done by referring to the patient's documented reports. Thus, it is very important that the information pertaining to the patient's health is well documented. Insurance companies do not provide preventive care to patients; preventive care is given by the provider. The amount that has to be paid for a premium is fixed and is not related to the patient's interventions. Proper documentation is not helpful in reducing the cost of healthcare services provided to the patient.
The nurse is recording specific demographic information about a patient in a hospital. Which section of the traditional source record does the nurse use to record this information?
A. Nurses' notes *B. Admission sheet C. Graphic sheet and flow sheet D. Nurse's admission assessment RATIONALE: Demographic information includes the legal name, identification number, gender, age, birth date, marital status, and occupation of the patient. Demographic information also includes health insurance, nearest relative to notify in an emergency, religious preference, name of attending physician, and date and time of patient's admission. This information is included on the admission sheet section. Nurses' notes include information about the assessment, nursing diagnosis, planning, implementation, and evaluation of patient care. Information about repeated observations and measurements such as vital signs, daily weights, and intakes and outputs are included under the graphic sheet and flow sheet section. The nurse's admission assessment section includes a summary of the patient's nursing history and physical examination.
The nurse understands that documentation is an important part of nursing care. What are the advantages of effective documentation? Select all that apply.
A. Repetition of therapy *B. Saving time *C. Minimizing error *D. Effective continuity of patient care E. Omission of treatment RATIONALE: Effective documentation saves time in finding the patient's details, change in status, treatment plans, and the treatments administered. It minimizes errors in treatment because all the details are mentioned in the document. It enhances and ensures effective continuity of patient care as the relevant details, outcomes of treatment, and the quality of patient care are noted. Effective documentation reduces repetition of therapy, because the treatment or therapy that has been done is mentioned in the document. It also stops omission of treatment, because the treatment plan is clearly mentioned in the document. TEST-TAKING TIP: This is a good example of a question where common sense should prevail. Would you ever want to repeat therapy or omit treatment? The choices, "Repetition of therapy" and "Omission of treatment" are easily eliminated by staying calm and examining the choices individually.
A patient is diagnosed with acute renal failure due to diabetes. Following treatment, the patient recovers. The patient is being discharged to home on insulin. The nurse is preparing a discharge summary for the patient. What information should the nurse provide in the discharge summary? Select all that apply.
A. The entire biographical information of the patient *B. The contact information of the healthcare provider *C. The step-by-step instructions for self-administration of insulin D. The investigatory procedures performed during the period of hospitalization *E. The signs and symptoms that have to be reported to the healthcare provider RATIONALE: Proper discharge planning is important to prepare patients for an effective and timely discharge from a healthcare institution. This is necessary to facilitate cost savings and ensure reimbursement. Contact information of the healthcare providers is documented to help the patients contact them when needed. Step-by-step instructions about the procedures should be provided so that the patient can refer to them while doing self-care procedures. Warning signs and symptoms that require the healthcare providers' attention should be documented in the discharge summary. Detailed biographical information of the patient and all the investigations done during the period of hospitalization are not required to be documented in a discharge summary.
The primary healthcare provider orders a clear liquids diet for a patient with gastritis. On the first day, the patient consumes soup and tolerates it well. How does the nurse document this finding?
A. The patient had soup and tolerated it well. B. The patient had soup while watching a football game. *C. The patient had 2 cups of soup, which was tolerated well. D. The patient had soup, 2 cp and was w.t., w.a.p. RATIONALE: Documenting the exact measurement increases the accuracy of the report. Charting with generic statements such as, "The patient had soup and tolerated it well," does not provide detailed information. However, details unrelated to the patient's health, such as "The patient watching a football game," are unnecessary and should be avoided. The nurse does not use any nonstandard abbreviations. This may cause misinterpretation and errors in treatment. Only standard abbreviations, acronyms, and symbols are used. TEST-TAKING TIP: Look for choices that support patient safety. Accuracy and clarity in recording are part of safe care. Use of nonstandard abbreviations risks being unclear and unsafe!
