A legal nurse consultant explains to a group of nursing students that the medial record serves what purpose? Select all that apply.
A method to gather research data
Determining eligibility for reimbursement
Providing client education
Legal document of car
...
A nurse is caring for a patient who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called:
charting by exception
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 nursing implemen
SOAP charting
There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many health care providers questioning the rationale for this change in practice. What potential advantage of EHRs should administrator
Improved continuity of care
A legal nurse consultant explains to a group of nursing students that the medial record serves what purpose? Select all that apply.
Determining eligibility for reimbursement
Legal document of care
A method to gather research data
Promoting effective communication between caregivers
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
It documents assessments on separate forms.
It provides quick acc
...
The nurse is preparing to leave the unit for lunch. What type of communication method should the nurse use?
Written handoff
Focus note
Verbal handoff
Patient Assessment Instrument
Verbal handoff
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, patients:
Have the right to copy their health records.
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry?
"Patient is guarding her abdomen and occasionally moaning."
"Patient complaining of abdominal
Patient complaining of abdominal pain rated 8/10.
A nurse has completed an assessment of a client with cholecystitis and is about to document the findings. Which statement best reflects accurate documentation?
Client was interviewed about previous history of
hypertension.
Skin pale, warm, and dry without
Skin pale, warm, and dry without evidence of lesions.
The nurse prepares information to provide to the nurse scheduled to work the next shift. Which type of communication is the nurse preparing?
hand-off report
A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply):
complete concise accurate biased timely organized
accurate
organized
complete
timely
concise
Abnormal assessment findings are clearly outlined in which documentation format?
Narrative charting
Focus note
PIE charting
Charting by exception
Charting by exception
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?
SBAR
SOAP
DAR
PIE
SBAR
A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?
Progress notes
Plan of care
Problem list
Data
progress notes
A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has bee
Repeating the measurement with a different sphygmomanometer and stethoscope
The nurse is caring for a client with influenza symptoms and is documenting the initial and ongoing assessment database. What would the nurse emphasize as the major rationale for this action?
Maximizing the efficiency of care
Facilitating achievement of p
Promoting communication between disciplines
A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following?
Observation and inspection
Interpretation and inference
Data and results
Subjective data and objective da
...
A client is being discharged home. The discharge note that the nurse writes for this client provides information for what purpose?
Resources and strategies for managing the client at home Maintaining an accurate list of medications the client has taken In
Resources and strategies for managing the client at home
The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks?
Vulnerability to legal liability since the n
Vulnerability to legal liability since the nurse's safe, routine care is not recorded.
A hospital is revising the policies and procedures surrounding documentation in an effort to align practices with the Health Information Technology for Economic and Clinical Health (HITECH) Act. How can the requirements of this legislation best be met?
In
Increase the use of electronic health records (EHRs) in the hospital.
A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data?
Focused assessment form
Ongoing assessment form
Open-ended form
Frequent assessment form
focused assessment form
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?
DAR
SOAP
SBAR
PIE
SBAR
The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"after listening to client's lung sounds, both lungs appeared clear."
"client's lung sounds were auscultated with st
bilateral lung sounds clear.
What is the name of the information program mandated by the federal government for the initial and ongoing assessment of Medicare and Medicaid clients in the home care setting?
APIE
OASIS
SOAPIE
CAME
OASIS
The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form
prevents missed questions during data collection
A client is having frequent blood pressure and blood glucose measurements to regulate an insulin infusion. Which type of documentation should the nurse use for this data?
Flow sheet
Checklist
Narrative note
Specialty assessment form
flow sheet
A nurse is recording some vital signs in a 12-year-old girl's chart when the girl asks why the nurse is writing all that information down. Which of the following should the nurse mention to this client as reasons for documenting assessment findings? Selec
To prevent delays in carrying out the plan of care
To determine the educational needs of the client
When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason?
It becomes the foundation for the entire nursing process.
A computerized risk assessment report correlates data and provides scores on various aspects of clients in the health care facility. Why would this be beneficial for client care?
Notifies health care providers when clients show clinical signs of deterioration
Nurses are aware that "handoff" can significantly increase the risk for errors. Common examples of "handoffs" are as follows (check all that apply):
when a patient is transferred from the PACU to the floor
upon admission to the ED
when a nurse leaves for
at change of shift
when a nurse leaves for lunch
when a patient is transferred from the PACU to the floor
Which of the following examples of documentation best exemplifies sound clinical documentation practices?
"Client is anxious during questioning regarding health history and family history."
"Abnormal chest sounds noted during posterior chest auscultation.
Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter.
Which of the following data entries follows the recommended guidelines for documenting data?
"Patient kidneys are producing sufficient amount of measured urine."
"Patient complained about the quality of the nursing care provided on previous shift."
"Follo
Following oxygen administration, vital signs returned to baseline.
The nurse completes documentation for a client. Which statement should be questioned?
Apical heart rate 88 and regular
Dressing on lower leg has some purulent drainage
Bowel sounds present all 4 quadrants 24/minute
Client reports pain as a 4 on a scale fr
Dressing on lower leg has some purulent drainage
A group of nursing students are reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes?
I
It provides a chronologic source of client assessment data.
The nurse responds to a call light for a client rating their pain "ten out of ten." The nurse's initial inspection reveals the client is watching videos and appears to be at ease physically and emotionally. How should the nurse validate the client's subje
Perform further assessments addressing various aspects of the client's pain.
While the nurse performs the initial assessment, the client states "This is my first hospitalization and I have had no previous surgeries." How would the nurse document this information?
Client denies prior hospitalizations and surgeries
A nurse is explaining to other nurses on the unit about diagnosis-related groups (DRGs). On what documentation do insurance companies base their payment approval/disapproval?
Diagnosis codes
A nurse is conducting client assessments in a long-term care facility. The manager of the facility has requested that the clinical staff use assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas,
Nursing minimum data set
A nurse is interpreting and making inferences from the data. The nurse is involved in which phase of the nursing process?
Implementation
Evaluation
Planning
Analysis
analysis
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use?
An assessment flow chart
While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding?
"Reddened area noted on skin surface superficial to client's coccyx."
"Impai
Area of nonblanching erythema noted over client's coccyx, 2 cm � 2 cm.
A nurse is explaining to a new client that the office uses electronic health records (EHRs) for all clients. The client says that at his last office, they used electronic medical records (EMRs). He asks whether these are the same thing. The nurse explains
A record supplied by a physician in which diagnoses and prescribed treatments are recorded
The nurse documents data immediately after assessing the patient. This is an example of:
point of care documentation
Which patient medical record does the nurse consult when determining activity orders for the patient?
computerized provider order entry
The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situation
When communicating a patient's change in condition to the patient's physician.
A nurse is providing a verbal update to a client's primary care provider because of the client's worsening nausea. When using an SBAR format to provide a report, the nurse should complete the report with which statement?
I think this client would benefit from an antiemetic.
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for quality assurance purposes?
Reimbursement for care provided
Evaluate nursing care provided
Evidence in a situation of wrongdoing
Dis
Evaluate nursing care provided
A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following?
Data and results
Observation and inspection
Interpretation and inference
Evaluate nursing care provided S
Subjective data and objective data
The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?
Assessment data in the medical record
Client and family requests
Medical diagnosis
Standards o
Assessment data in the medical record
A patient with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the patient's chart. The nurse knows to look at what part of the patient's medical
progress notes
A nurse is conducting client assessments in a long-term care facility. The manager of the facility has requested that the clinical staff use assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas,
Nursing minimum data set
How does the client's medical record affect financial reimbursement? (select all that apply.)
Insurance companies audit client records to ensure that billing is accurate
Documentation does not support specific interventions that a care provider ordered
Fi
Insurance companies audit client records to ensure that billing is accurate
A 54-year-old client is receiving a follow-up assessment in a clinic, following abnormal findings on her recent mammogram. Which of the following statements best reflects appropriate documentation by the nurse?
Client has unkempt appearance and avoids eye contact
The nurse is reviewing the patient's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the patient's status?
progress notes
Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse?
PIE charting
Problem-oriented medical record
Focus charting
Charting by exception
Charting by exception