Chapter 18: Documenting & Reporting

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Basic Nursing
Chapter 18
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1

Multiple Choice

Identify the choice that best completes the statement or answers the question.

A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client’s condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first?

1)Study the discharge plan.

2)Check the graphic data for vital signs.

3)Examine the history and physical.

4)Look for an advance directive.

ANS: 4

The advance directive, which should be located in a special section of the patient’s medical record, should be examined first because the patient’s symptoms indicate that he may need to be resuscitated. The advanced directive contains information about the patient’s wishes for intensity of care and actions that should be taken in the event of a life-threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data are to record assessment done frequently, such as vital signs. The history and physical provide a detailed summary of the patient’s current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data.

2

A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system?

1)It involves a cooperative effort among various disciplines.

2)The system requires diligence in maintaining a current problem list.

3)Data may be fragmented and scattered throughout the chart.

4)It allows the nurse to provide information in an unorganized manner.

ANS: 3

A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. The problem-oriented medical record requires a cooperative effort among disciplines and diligence in maintaining a current problem list. Narrative charting allows the nurse to provide information in a disorganized manner.

3

The patient’s medical record contains the following documentation:

06/05/05 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104°F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18 gauge IV catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.—Ann. Davids, RN

Which type of charting has the nurse used?

1)Narrative

2)Focus

3)SOAP

4)PIE

ANS: 1

The nurse used narrative charting when documenting the condition of this newly admitted patient. This format is free text description of the patient status and nursing care. Focus charting highlights the patient’s concerns, problems, and strengths in a three-column format. SOAP is an acronym for subjective data, objective data, assessment, and plan. This charting format is used to address single problems or to write summative notes. PIE is an acronym for problem, interventions, and evaluation. This charting method also addresses problems.

4

The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? CBE

1)Reduces the time nurses spend charting

2)Addresses the patient’s concerns holistically

3)Establishes an ongoing care plan from admission

4)Is most useful when constructing a timeline of events

ANS: 1

An advantage of CBE is that it reduces the amount of time that nurses must spend documenting. CBE assumes that unless a separate entry is made, all standards have been met with a normal response. Focus charting addresses the patient’s concerns holistically. PIE charting establishes an ongoing care plan from admission. Narrative charting is especially useful when attempting to construct timelines of events.

5

A patient is admitted to the emergency department with a stroke. After being stabilized, the patient’s needs are best met if the nurse documents a care plan that provides for

1)Acute interventions

2)Patient teaching

3)Discharge needs

4)Family health data

ANS: 3

The patient’s potential discharge needs should be evaluated when the patient first enters the healthcare facility. After the patient is admitted, discharge needs should be continually reevaluated and documented throughout the patient’s hospitalization.

6

The patient’s health record contains the following provider’s order: furosemide 40 mg intravenously STAT. If the nurse later needed to know when the medication had been given and the patient’s response to the medication, where would he look?

1)Progress notes

2)Graphic record

3)Narrative notes

4)MAR

ANS: 3

The nursing narrative note will contain documentation about the time the medication was administered and the patient’s response to the medicine. In contrast, the MAR will only contain documentation about when the medication was given, not the patient’s response. The physician’s progress note contains documentation about why the furosemide was ordered. The graphic record will not contain charting about the medication but will contain information about the patient’s output.

7

A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1 hour PRN pain. When should the nurse administer the medication?

1)Every hour around-the-clock

2)Immediately after taking off the order

3)As needed, but not more than once per hour

4)1 hour after the last administered dose

ANS: 3

PRN is the abbreviation for “as needed.” The nurse should administer the medication after assessing that the patient needs the medication or the patient requests it and at least 1 hour has elapsed since the last dose. STAT medications must be administered immediately.

8

The nurse administers heparin 5000 units subcutaneously at 2100 and documents in the medication administration record that the dose was administered. What other information is important for the nurse document?

1)Injection site

2)Previous site of administration

3)Patient response to medication

4)Heart rate prior to administration

ANS: 1

After administering an injection, the nurse must document the injection site to prevent the patient from receiving repeated injections in the same location. Heparin 5000 units subQ was prescribed for the patient. The previous route of administration is already documented on the MAR from the previous dose and would not be noted in the entry for the current dose. The patient’s response to medication is recorded in the nurse’s narrative note in the traditional paper for the electronic health record. When the nurse signs out that the drug was given in the medication administration record, she is validating that she administered the drug according to the physician’s order. Heparin does not affect heart rate.

9

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement?

1)Hypertension

2)Rheumatoid arthritis

3)Postoperative colon resection

4)Follow all three plans

ANS: 3

The postoperative colon resection integrated plan of care should be followed; however, modifications should be made to meet the patient’s other health needs. Therefore, portions of the hypertension and rheumatoid arthritis integrated plan of care may be added to the postoperative colon resection plan of care.

10

The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone order for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order?

1)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain. Kay Andrews, RN

2)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN

3)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain V.O.: Dr. D. Kelly/Kay Andrews, RN

4)09/02/13 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN

ANS: 2

Correct documentation of a telephone order is as follows: “09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN” (date, time, medication, route, frequency of dose, circumstances under which it is to be given, prescriber’s name and title, nurse’s name and title.) The other options demonstrate incomplete documentation of a telephone order.

11

A patient refuses a dose of medication. How should the nurse document the event?

1)Patient is uncooperative and refuses the prescribed dose of digoxin.

2)Patient refuses the 0900 dose of digoxin.

3)Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin.

4)0900 dose of digoxin not given.

ANS: 2

“Patient refuses the 0900 dose of digoxin” objectively describes the event in which the patient refuses to take his 0900 dose of digoxin. “0900 dose of digoxin not given” provides no explanation as to why the medication was not given. The other two options offer judgmental information, which should be avoided when charting.

12

The nurse makes a mistake while documenting in the patient’s health record. Which action should the nurse take?

1)Use an opaque white fluid to cover the documentation error.

2)Completely cover the documentation error with black ink.

3)Draw a line through the error and initial the change.

4)Use correction tape to make the documentation correct.

ANS: 3

The nurse should draw a single line through the documentation error and place her initials next to the change. In some institutions, the nurse must also write the words “error” or “mistaken entry” above the error. The nurse should never use opaque cover-up liquid or correction tape. It is not acceptable to alter the patient’s health record as though the error was not made. Making note of the correction in documentation makes it clear to others what happened.

13

At 1000 on 11/14/10, the nurse takes a telephone order for “metoprolol 5 mg intravenously now.” What is the latest date and time the nurse will expect the prescriber to countersign the order?

1)11/14/13 at 1200

2)11/14/13 at 2200

3)11/15/13 at 1000

4)11/16/13 at 1000

ANS: 3

The prescriber must countersign all verbal and telephone orders within 24 hours.

14

The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order?

1)Repeat the order to the prescriber even if she believes she understood the order correctly.

2)Immediately notify the pharmacy of the order and verify it with a pharmacist.

3)Ask the unit secretary to listen to the prescriber on the phone to verify the order.

4)Transcribe the order onto note paper and verify the dosage in a drug handbook.

ANS: 1

The nurse should repeat the order to the prescriber even if she believes she understood it entirely. If possible, she should have a second nurse (not the unit secretary) listen to the order to verify accuracy. Only the prescribing provider, not the pharmacist, can verify the order. The nurse should transcribe the order directly on the patient’s chart. Transcribing it on a piece of paper and then copying it again introduces one more chance of error.

15

A resident in a long-term care facility receiving Medicare funds requires care for a stage 2 pressure ulcer. How often must the nurse document this patient’s care?

1)Every 2 weeks

2)Every shift

3)Every week

4)Every 3 months

ANS: 2

When a patient requires Medicare-reimbursed services, such as wound care, documentation is required every shift. Those who require assistance with medications, nutrition, and activities of daily living must have a summary written by a registered nurse or licensed practical nurse every 2 weeks. A summary must also be recorded on a weekly basis for those who require wound care. The Minimum Data Set must be updated every 3 months.

16

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident of a long-term care facility?

1)14 days

2)3 days

3)2 days

4)24 hours

ANS: 1

Federal regulations require that a resident be evaluated using the Minimum Data Set within 14 days of admission to a long-term care facility.

17

A client is admitted to a long-term care facility. The nurse knows that federal law requires the use of

1)The Minimum Data Set (MDS) for assessment

2)Situation-background-assessment-recommendation (SBAR) for reporting

3)Healthcare Financing Administration guidelines prior to surgery

4)Joint Commission guidelines for discharge planning

ANS: 1

Federal regulations require that a resident be evaluated using the Minimum Data Set (MDS) within 14 days of admission to a long-term care facility. SBAR is a technique used for communicating and organizing a hand-off report. HCFA guidelines govern home healthcare documentation. Joint Commission guidelines do apply to long-term care facilities, but only the MDS assessment is mandated by federal law.

18

The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeon’s order? The nurse

1)Performs oral care

2)Assists the patient out of bed

3)Assists the patient with bathing

4)Changes the patient’s operative dressings

ANS: 2

OOB is the abbreviation for “out of bed.” The nurse is following the physician’s order when she assists the patient out of bed in the morning. OOB does not indicate that the nurse should perform oral care, assist with bathing, or change the patient’s postoperative dressings.

19

What is the purpose of completing an occurrence report?

1)Provide a legal defense should the patient seek legal action after an unusual occurrence

2)Track problems and identify areas for quality improvement

3)Report errors to the Food and Drug Administration

4)Report medical errors to the Joint Commission

ANS: 2

Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal defense should a patient seek legal action or to report errors to the FDA or Joint Commission.

20

The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports?

1)“Occurrence reports track problems and identify areas for quality improvement.”

2)“Occurrence reports are required by the Food and Drug Administration to report drug errors.”

3)“The Joint Commission requires occurrence reports for all client falls.”

4)“Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence.”

ANS: 1

Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal information should a patient seek legal action. As an internal communication and documentation tool, occurrence reports are not required to be reported to the FDA or Joint Commission.

21

Which of the following is a disadvantage of paper health records?

1)Assist collaboration

2)Provide cautionary reminders

3)Are sometimes illegible

4)Serve as a resource

ANS: 3

A disadvantage of paper documentation systems is that they are sometimes illegible. This increases the risk for medication administration and other errors, as well as taking nurses' time to decipher handwriting and call providers.

22

The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall.

1)Patient found on floor in pain after falling out of bed.

2)Patient found on floor after falling out of bed; found by NAP Smith.

3)Patient fell out of bed but is currently in bed.

4)Patient reminded to not climb OOB after falling.

ANS: 2

Charting must be accurate and succinct. Only chart what you observe. Do not chart what others have observed as your own observation. Avoid judging patients; instead, chart objectively.

23

Which set of topics makes up a hand-off report given in a recommended format?

1)Data-action-response

2)Subjective-objective-assessment-plan

3)Situation-background-assessment-recommendation

4)Patient-diagnosis-medications-activity

ANS: 3

The SBAR (situation-background-assessment-recommendation) technique is used as a mechanism to give a hand-off report by enabling a focused communication between healthcare team members. DAR is used in Focus Charting®, and SOAP is a method for documenting nursing care. The nursing admission assessment is completed and documented at the time of admission.

24

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

Which statement by the student nurse indicates an understanding of the nursing Kardex®? Choose all correct answers.

1)“The Kardex® pulls data from multiple areas of the patient’s chart.”

2)“The Kardex® is usually kept at the patient’s bedside.”

3)“The Kardex® is used to document patient response to interventions.”

4)“The Kardex® summarizes the plan of care and guides nursing care.”

ANS: 1, 4

The Kardex® is a tool that pulls data from multiple areas of the patient’s health record and helps guide nursing care. Responses to interventions are documented on flow sheets and in nurses’ notes. Kardexes® are paper forms that are kept together in a portable file at the nurses’ station to allow all team members access to the summary information. The file is portable, so it could be carried to the bedside briefly; however, it is not stored there, as a general rule.

25

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

Which action by the nurse breaches patient confidentiality? Select all that apply.

1)Leaving patient data displayed on a computer screen where others may view it

2)Remaining logged on to the computer system after documenting patient care

3)Faxing a patient report to the nurses’ station where the patient is being transferred

4)Informing the nurse manager of a change in the patient’s condition

ANS: 1, 2

Leaving patient data displayed on a computer screen where others may view them breaches patient confidentiality. The nurse should log off the computer immediately after use. Faxing a report to the nurses’ station receiving a patient does not breach patient confidentiality because it is located at the nurses’ station out of others’ view. Anyone directly involved in the patient’s care has the right to know about the patient’s condition without breaching patient confidentiality.

26

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

Which statement by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply.

1)“I can wait until the end of the shift to document my care.”

2)“Charting every 2 hours is the most appropriate way to document nursing care.”

3)“I find it easier to chart before I go to lunch and then after my shift report.”

4)“I should chart as soon as possible after nursing care is given.”

ANS: 1, 2, 3

Documentation should be performed as soon as possible after the nurse makes an assessment or provides care. The longer the nurse waits, the less accurate the documentation will be. Leaving documentation until the end of the shift may cause important details to be omitted or mistaken. It is not necessary to complete documentation on a strict schedule, such as every 2 to 4 hours. Even waiting until lunch or reporting after the shift is over is too long of a period of time for accurate documentation. In addition, the objectivity of documentation might be influenced by the discussion that occurs during report.

27

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

The nurse who understands the electronic health record (EHR) can do which of the following? Select all that apply.

1)Facilitate evidence-based nursing practice

2)Promote efficient use of the nurse’s documentation time

3)Reduce the opportunity for interdisciplinary collaboration

4)Ensure improved client safety and outcomes

ANS: 1, 2, 4

Electronic health records (EHR) have many advantages, including the facilitation of evidence-based nursing practice, efficient use of the nurse’s documentation time, and improved client safety and outcomes. The EHR does not impair interdisciplinary collaboration; rather, the EHR fosters communication and collaboration among healthcare team members.

28

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

In performing a hand-off report, the nurse should communicate information on which of the following? Select all that apply.

1)Teaching performed

2)Any change in client status

3)Treatments administered

4)Hygiene measures performed

ANS: 1, 2, 3

Hand-off reports include any client teaching done, therapies and treatments administered, and changes in the client’s status. Hygiene care is routinely done in inpatient settings and is usually recorded on a flow sheet. Hand-off reports should be succinct and not contain routine information.

29

True/False

Indicate whether the statement is true or false.

____ 1. The nursing Kardex® is part of the patient’s permanent health record.

ANS: F

The Kardex is not part of the patient’s permanent medical record. It is a tool that helps guide nursing care. It changes as different care is required.