Chapter 26: Documentation and Informatics [Practice Test] Flashcards
After providing care, a nurse charts in the patient’s record. Which entry should the nurse
document?
a. Appears restless when sitting in the chair
b. Drank adequate amounts of water
c. Apparently is asleep with eyes closed
d. Skin pale and cool
ANS: D
A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. An objective description is the result of direct observation and measurement. For example, “B/P 80/50, patient diaphoretic, heart rate 102 and regular.” Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the patient. Use of exact measurements establishes accuracy. For example, a description such as “Intake, 360 mL of water” is more accurate than “Patient drank an adequate amount of fluid
A home health nurse is preparing for an initial home visit. Which information should be included in the patient’s home care medical record? a. Nursing process form
b. Step-by-step skills manual
c. A list of possible procedures
d. Reports to third party payers
ANS: D
Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third party payers. An interprofessional plan of care is used rather than a nursing process form. A step-by-step skills manual and a list of possible procedures are not in the record.
A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using?
a. Clinical decision support system
b. Nursing process design c. Critical pathway design d. Computerized provider order entry system
ANS: C
One design model for Nursing Information Systems (NIS) is the protocol or critical pathway design. With this design, all health care providers use a protocol system to document the care they provide. A clinical decision support system is based on “rules” and “if-then” statements, linking information and/or producing alerts, warnings, or other information for the user. The
nursing process design is the most traditional design for an NIS. This design organizes documentation within well-established formats such as admission and postoperative
assessments, problem lists, care plans, discharge planning instructions, and intervention lists or notes. Computerized provider order entry (CPOE) is a process by which the health care provider directly enters orders for patient care into the hospital information system.
Identify the purposes of a health care record. (Select all that apply.)
a. Communication
b. Legal documentation c. Reimbursement
d. Education
e. Research
f. Nursing process
ANS: A, B, C, D, E
The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing (reimbursement), education, research, and auditing/monitoring. Nursing process is a way of thinking and performing nursing care; it is not a purpose of a health care record.
A new nurse asks the preceptor why a change-of- shift report is important since care is documented in the chart. What is the preceptor’s best response?
a. “A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care.”
b. “A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs.”
c. “A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities.”
d. “A change-of-shift report provides important information to caregivers and develops relationships within the health care team.”
ANS: A
Properly performed, a hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care. Reimbursement costs and research priorities/opportunities are functions of the medical record. The purpose of the change-of-shift
report is not to establish relationships but to ensure patient safety and continuity of care
A nurse developed the following discharge summary sheet. Which critical information should
be added?
TOPIC DISCHARGE SUMMARY
Medication
Diet
Activity level
Follow-up care
Wound care
Phone numbers
When to call the doctor
Time of discharge
a. Kardex form
b. Admission nursing history c. Mode of transportation
d. SOAP notes
ANS: C
List actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. In some settings, a Kardex, a portable “flip-over” file or notebook, is kept at the nurses’ station. A Kardex is for nurses, not for patients to take upon discharge. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style
A nurse has provided care to a patient. Which entry should the nurse document in the patient’s record?
a. “Patient seems to be in pain and states, ‘I feel uncomfortable.’” b. Status unchanged, doing well
c. Left abdominal incision 1 inch in length without redness, drainage, or edema
d. Patient is hard to care for and refuses all treatments and medications. Family present
ANS: C
Use of exact measurements establishes accuracy. Charting that an abdominal wound is “5 cm in length without redness, drainage, or edema” is more descriptive than “large wound healing well.” Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as “status unchanged” or “had a good day.” It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions. “Patient is hard to care for” is a personal opinion and should be avoided. It is also a
critical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, “Refuses all treatments and medications.”
A nurse is using the source record and wants to find the daily weights. Where should the nurse look? a. Database b. Medical history and examination c. Progress notes d. Graphic sheet and flow sheet
ANS: D
In a source record, the patient’s chart has a separate section for each discipline (e.g., nursing, medicine, social work, respiratory therapy) in which to record data. Graphic sheets and flow sheets are records of repeated observations and measurements such as vital signs, daily
weights, and intake and output. In the problem-oriented medical record, the database section contains all available assessment information pertaining to the patient (e.g., history and physical examination, the nurse’s admission history and ongoing assessment, the dietitian’s assessment, laboratory reports, radiologic test results). In the source record, the medical history and examination contain results of the initial examination performed by the physician, including findings, family history, confirmed diagnoses, and medical plan of care. In the source record, the progress notes contain an ongoing record of the patient’s progress and response to medical therapy and a review of the disease process; it often is interdisciplinary
and includes documentation from health-related disciplines (e.g., health care providers, physical therapy, social work).
A nurse is a member of an interdisciplinary team that uses critical pathways. According to the
critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?
a. Focus charting using the DAR format.
b. Add this data to the problem list.
c. Document the variance in the patient’s record.
d. Report a positive variance in the next interdisciplinary team meeting.
ANS: C
A variance occurs when the activities on the critical pathway are not completed as predicted, or the patient does not meet expected outcomes. An example of a variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a patient progresses more rapidly than expected (e.g., use of a Foley catheter may be discontinued a day early). When a nurse is using the problem-oriented medical record, after analyzing data, health care team members identify problems and make a single problem list. A type of narrative format charting is focus charting. It involves the use of DAR notes, which include D—Data (both subjective and objective), A—Action or nursing intervention, and R—Response of the patient (i.e., evaluation of effectiveness).
A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient?
a. Upon admission
b. Right before discharge
c. After the congestion is treated
d. When the primary care provider writes the order.
ANS: A
Ideally, discharge planning begins at admission. Right before discharge is too late for discharge planning. After the congestion is treated is also too late for discharge planning. Usually the primary care provider writes the order too close to discharge, and nurses do not need an order to begin the teaching that will be needed for discharge. By identifying discharge needs early, nursing and other health care professionals can begin planning for home care, support services, and any equipment needs at home.
A patient is being discharged home. Which information should the nurse include?
a. Acuity level
b. Community resources
c. Standardized care plan
d. Kardex
ANS: B
Discharge documentation includes medications, diet, community resources, follow-up care, and whom to contact in case of an emergency or for questions. A patient’s acuity level, usually determined by a computer program, is based on the type and number of nursing
interventions (e.g., intravenous [IV] therapy, wound care, ambulation assistance) required over a 24-hour period. Acuity level can be used for staffing and billing. Some institutions use standardized care plans to make documentation more efficient. The plans, based on the
institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients who have similar health problems. In some settings, a Kardex, a portable “flip-over” file or notebook, is kept at the nurses’ station. Most Kardex forms have an activity and treatment section and a nursing care plan section, which organize information for quick reference.
A nurse developed the following discharge summary sheet. Which critical information should be added? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge a. Kardex form b. Admission nursing history c. Mode of transportation d. SOAP notes
ANS: C
List actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. In some settings, a Kardex, a portable “flip-over” file or notebook, is kept at the nurses’ station. A Kardex is for nurses, not for patients to take upon discharge. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style
A home health nurse is preparing for an initial home visit. Which information should be included in the patient’s home care medical record?
a. Nursing process form
b. Step-by-step skills manual
c. A list of possible procedures
d. Reports to third party payers
ANS: D
Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third party payers. An interprofessional plan of care is used rather than a nursing process form. A step-by-step skills manual and a list of possible procedures are not included in the record.
A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning and for meeting quality improvement
within and across facilities. Which task did the nurse just complete?
a. A focused assessment/specific body system
b. The Resident Assessment Instrument/Minimum Data Set
c. An admission assessment and acuity level
d. An intake assessment form and auditing phase
ANS: B
You assess each resident in a long-term care agency receiving funding from Medicare and Medicaid programs using the Resident Assessment Instrument/Minimum Data Set (RAI/MDS). This documentation provides standardized protocols for assessment and care planning and a minimum data set to promote quality improvement within and across facilities. A focused assessment is limited to a specific body system. An admission assessment and
acuity level is performed in the hospital. An intake assessment is for home health. There is no such thing as an auditing phase.
A nurse is giving a hand-off report to the oncoming nurse. Which information is critical for
the nurse to report?
a. The patient had a good day with no complaints.
b. The family is demanding and argumentative.
c. The patient has a new pain medication, Lortab.
d. The family is poor and had to go on welfare
ANS: C
Relay to staff significant changes in the way therapies are to be given (e.g., different position for pain relief, new medication). Don’t simply describe results as “good” or “poor.” Be specific. Don’t use critical comments about patient’s or family’s behavior, such as “Mrs. Wills is so demanding.” Don’t engage in idle gossip.
