Ch.9 Recording and Reporting

Question 1

Identify uses for medical records.

Answer 1

Besides serving as a permanent health record, the collective information about a client provides a means to share information among health care providers, thus ensuring client safety and continuity of care.

Occasionally, medical records also are used to investigate quality of care in a health agency, demonstrate compliance with national accreditation standards, promote reimbursement from insurance companies, facilitate health education and research, and provide evidence during malpractice lawsuits.

Question 2

List components generally found in any client’s medical record.

Answer 2

It includes informationally typically found in paper charts as well as :

• Vital signs
• Diagnoses
• Medical history
• Immunization dates
• Progress notes
• Lab data
• Imaging reports
• Allergies

Question 3

List legal defensible characteristics of written charting.

Answer 3

• Ensure that the client’s name appears on each page.
• Never chart for someone else.
• Use the specified color of ink and ballpoint pen, or enter data on a computer.
• Date and time stamp each entry as it is made.
• Chart promptly after providing care.
• Make entries in chronological order. • Identify documentation that is out of chronological sequence with the words “late entry.”
• Write or print legibly.
• Use correct grammar and spelling.

Question 4

Differentiate between source-oriented records and problem-oriented records

Answer 4

This type of record contains separate forms on which physicians, nurses, dietitians, physical therapists, and other health care providers make entries about their own specific activities in relation to the client’s care.

In contrast to source-oriented records that contain numerous locations for information, problem-oriented records contain four major components: the database, the problem list, the plan of care, and the progress notes.

Question 5

Identify methods of charting

Answer 5

Narrative Charting

SOAP charting

Focus charting

PIE charting

Charting by exception

Electronic computerized charting

Question 6

List advantages and disadvantages of an electronic medical records

Answer 6

Advantages:

• The information is always legible.
• It automatically records the date and time of the documentation.
• The abbreviations and terms are consistent with agency-approved lists.
• It eliminates trivia.

Disadvantages:

• Systems are expensive to purchase.
• Systems vary with institutions necessitating extensive training of new hires.
• Competency in using the system requires significant time. IT support staff are required.
• Passwords must be changed regularly.
• Downtime during system upgrades and power or electronic failures can interrupt and delay documentation and access to the full record.

Question 7

Explain the purpose and applications associated with the Health Insurance Portability and Accountability Act (HIPAA)

Answer 7

HIPAA regulations require health care agencies to safeguard written, spoken, and electronic health information in the following ways:

• The names of clients on charts can no longer be visible to the public.
• Clipboards must obscure identifiable names of clients and private information about them.
• Whiteboards must be free of information linking a client with a diagnosis, procedure, or treatment.
• Computer screens must be oriented away from public view.
• Flat screen monitors are more difficult to read at obtuse angles.

Question 8

List aspects of documentation required in the medical records of all clients cared for in acute settings

Answer 8

Current standards of TJC require that the medical records of clients cared for in acute care agencies (e.g., hospitals) must identify the steps of the nursing process (assessment, diagnosis, planning, implementation, and evaluation of outcomes).

Question 9

Discuss why it is important to use only approved abbreviations when charting

Answer 9

Many abbreviations have common meanings; however, nurses cannot assume that all abbreviations are interpreted the same universally.

Some may have one meaning in one locale or agency but may mean something different or be unfamiliar in another.

To avoid confusion among caregivers and misinterpretation if the chart is subpoenaed as legal evidence, each agency provides a list of approved abbreviations and their meanings.

When documenting, nurses must use only those abbreviations on the agency’s approved list.

Question 10

Explain how to convert traditional time to military time

Answer 10

The use of military time avoids confusion because no number is ever duplicated, and the labels AM , PM , midnight, and noon are not needed.

Military time begins at midnight (2400 or 0000). One minute after midnight is 0001.

A zero is placed before the hours of one through nine in the morning; for example, 0700 refers to 7 AM and is stated as “oh seven hundred.”

After noon, 12 is added to each hour; therefore, 1 PM is 1300. Minutes are given as 1 to 59.

Question 11

Identify written forms used to communicate information about clients

Answer 11

Nursing care plan: is a written or printed list of the client’s problems, goals, and nursing orders for client care.

Nursing Kardex: a quick reference for current information about the client and his or her care

Checklist: a form of documentation in which the nurse indicates the performance of routine care with a check mark or initials.

Flow Sheets: a form of documentation with sections for recording frequently repeated assessment data.

Question 12

List ways that healthcare workers exchange client information others than by reading the medical record

Answer 12

• Change-of-shift reports
• Client assignments
• Team conferences
• Rounds
• Telephone calls

Question 13

When writing source-oriented records, a ____________ style of charting is generally used.

Answer 13

Narrative

Question 14

____________ electronic charting is most useful for nurses when a terminal is available at the point of care or at the bedside.

Answer 14

Computerized

Question 15

____________ time is based on a 24-hour clock.

Answer 15

Military

Question 16

Charting by exception is a method in which nurses chart only ____________ assessment findings or care that deviates from a standard norm.

Answer 16

Abnormal

Question 17

The ____________ legislation was introduced to ensure the privacy of health records and to protect the rights of US citizens to retain their health insurance when changing employment.

Answer 17

HIPAA

(Health Insurance Portability and Accountability Act)

Question 18

Auditors examine client medical records to determine whether the care provided meets established criteria for ____________.

Answer 18

Reimbursement

Question 19

____________ charting is a modified form of SOAP charting.

Answer 19

Focus

Question 20

Nurses use ____________ to avoid documenting types of care that are regularly repeated.

Answer 20

Checklists

Question 21

When agencies can release private health information without the client’s prior authorization, it is called ____________ disclosures.

Answer 21

Beneficial

Question 22

According to HIPAA rules, client information is ____________ when transmitting via the Internet.

Answer 22

Encrypted

Question 23

Identify what is going on in the figure.

Answer 23

The figure shows nurses exchanging reports on their clients during a change of shift

Question 24

Explain the need for this procedure.

Answer 24

A change-of-shift report is a discussion between a nursing spokesperson from the shift that is ending and personnel coming on duty. It includes a summary of each client’s condition and current status of care. This helps the nurse on the next shift to provide uninterrupted care to their clients. To maximize the efficiency of change-of-shift reports, nurses should do the following:

• Be prompt so that the report can start and end on time.
• Come prepared with a pen and paper or clipboard.
• Avoid socializing during reporting sessions.
• Take notes.
• Clarify unclear information.
• Ask questions about pertinent information that may have been omitted.

Question 25

Writing information about the client and client care in chronological order

Answer 25

Narrative

Question 26

Documenting style more likely to be used in problem-oriented records

Answer 26

SOAP

Question 27

Documenting the client information electronically

Answer 27

Computerized

Question 28

Recording the client’s progress under the headings of problem, intervention, and evaluation

Answer 28

PIE

Question 29

Documenting abnormal assessment findings

Answer 29

Charting by exception

Question 30

Presented here, in random order, are steps taken by a nurse when exchanging information using the telephone. Write the correct sequence in the boxes provided.

1. Identifies themselves by name, title, and nursing unit
2. Obtains or states the reason for the call
3. Repeats information to ensure it has been heard accurately
4. Answers as promptly as possible

Answer 30

4. Answers as promptly as possible
5. Identifies themselves by name, title, and nursing unit
6. Obtains or states the reason for the call
7. Repeats information to ensure it has been heard accurately

Question 31

What are the reasons for maintaining a medical record?

Answer 31

Medical records are written collections of information about a person’s health, the care provided by health practitioners, and the client’s progress.

They also are referred to as health records or client records. Besides serving as a permanent health record, the medical record of a client provides a means of sharing information among health care workers, thus ensuring client safety and continuity of care.

Occasionally, medical records are also used to investigate quality of care in a health agency, to demonstrate compliance with national accreditation standards, to facilitate reimbursement from insurance companies, to facilitate health education and research, and to provide evidence during malpractice lawsuits.

Question 32

What evidence does the Joint Commission need in order to provide a health care facility with accreditation?

Answer 32

The Joint Commission requires the following documentation evidence to justify accreditation:

Initial assessment and reassessments physical, psychological, social, environmental, and self-care; education; and discharge planning Identification of nursing diagnoses or client needs

Planned nursing interventions or nursing standards of care for meeting the client’s nursing care needs including the education and training provided to the client and fall precaution strategies (The Joint Commission, 2012)

Nursing care provided

A client’s response to interventions and outcomes of care including pain management, discharge planning activities, and the client’s and/or significant other’s ability to manage continuing care needs

Question 33

How is a medical record maintained and who is responsible for maintaining the records?

Answer 33

The medical record may consist of various agency-approved paper forms, or the forms may be stored on the hard drive of a computerized record.

The hard-copy paper forms are placed in a chart (binder or folder that promotes the orderly collection, storage, and safekeeping of a person’s medical records).

The paper forms in the chart are color coded or separated by tabbed sheets.

Each person who writes in the client’s medical record is responsible for the information they record and can be summoned as a witness to testify concerning what has been written.

An electronic medical record stored on a computer is accessed by using a password and selecting the desired form from a menu.

Electronic records can be printed if a hard copy is desired.

All personnel involved in a client’s health care contribute to the medical record by charting, recording, or documenting (the process of entering information).

Question 34

What measures should a nurse take when documenting a medical record?

Answer 34

When documenting a medical record the following points should be kept in mind:

Each person who writes in the client’s medical record is responsible for the information they record and can be summoned as a witness to testify concerning what has been written.

Any writing that cannot be clearly read or that is vague, scribbled through, whited out, written over, or erased makes for a poor legal defense.

If documentation is substandard, the Joint Commission may withdraw or withhold accreditation.

Question 35

What are the different methods of communicating a client’s health-related details to other personnel of the agency?

Answer 35

Although the medical record serves as an ongoing source of information about the client’s status, nurses use other methods of communication to promote continuity of care and collaboration among the health personnel involved in the client’s care.

These methods are in written or verbal form.

The written form of communication includes the nursing care plan, the nursing Kardex, checklists, and flow sheets.

The verbal form includes change-of-shift reports, client assignments, team conferences, rounds, and telephone calls.

Question 36

A nurse at a health care facility uses the computer to store the health records for all the clients. All nurses caring for a particular client and using the system are required to ensure that the records are confidential.

What care should the nurse take to ensure that these data are not available to unauthorized personnel and are not misused?

Answer 36

The nurse can ensure that client data are confidential by the following:

Assigning an access number and password to authorized personnel who use a computer for health records.

These are kept secret and are changed regularly.

Using automatic save, using a screen saver, or returning to a menu if data have been displayed for a specific period Issuing a plastic card or key that authorized personnel use to retrieve information

Locking out client information except to those who have been authorized through a fingerprint or voice activation device

Blocking the type of information that personnel in various departments can retrieve.

• For example, laboratory employees can obtain information from the medical orders, but they cannot view information in the client’s personal history.

Storing the time and location from which the client’s record is accessed in case there is an allegation concerning a breech in confidentiality

Encrypting any client information transmitted via the internet