Documentation

Question 1

What is a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions, and patient responses in a health record?

Answer 1

Documentation

Question 2

What within a patient health care record is a vital aspect of nursing practice?

Answer 2

Documentation

Question 3

What is 21.5% of nursing practice time concerned with?

Answer 3

Documentation

Question 4

What needs to be accurate and comprehensive?

Answer 4

Documentation

Question 5

Which systems need to be flexible enough to retrieve clinical data, facilitate continuity of care, track patient outcomes, and reflect current standards of nursing practice?

Answer 5

Documentation

Question 6

What in a patient’s record provides a detailed account of the level of quality of care delivered?

Answer 6

Information

Question 7

The quality of care, the standards of regulatory agencies and nursing practice, and legal guidelines make documentation and ___ an extremely important nursing responsibility.

Answer 7

reporting

Question 8

Effective documentation can positively affect the quality of life and health outcomes for patients and minimize the risk of ___.

Answer 8

errors

Question 9

Accrediting agencies such as Accreditation Canada offer ___ for documentation.

Answer 9

guidelines

Question 10

___ and ___ practices differ among institutions and jurisdictions and are influenced by ethical, legal, medical, and agency guidelines.

Answer 10

Documentation

reporting

Question 11

As a member of the health care team, the nurse needs to communicate information about patients ___ and in a ___, effective manner.

Answer 11

accurately

timely

Question 12

___ recorded, reported, or communicated to other health care providers are confidential, and the confidentiality of these ___ must be protected.

Answer 12

Data

data

Question 13

What is a valuable source of data for all members of the health care team?

Answer 13

Medical Record

Question 14

Data entered into the ___ ___ facilitates interdisciplinary communication and care planning; provides a legal record of care provided; facilitates funding and resource management; and allows for auditing, monitoring, and evaluation of care provided.

Answer 14

medical record

Question 15

What serves as a source for research data and learning resources for nursing and health care education?

Answer 15

Medical Record

Question 16

What is one way in which health care team members communicate about patient needs and progress responses to care, individual therapies, content of conferences, patient education, and discharge planning?

Answer 16

Medical Record

Question 17

What to be clear to everyone reading the chart?

Answer 17

Plan of Care

Question 18

What should be the most current and accurate source of information about a patient’s health care status?

Answer 18

Medical Record

Question 19

In the medical record, as a nurse, always communicate the manner in which you conduct the ___ process with a patient.

Answer 19

nursing

Question 20

The admitting nursing ___ and ___ assessment are comprehensive and provide baseline data about the patient’s health status on admission to the facility.

Answer 20

history

physical

Question 21

Which data usually includes biographical information (e.g., age and marital status), method of admission, reason for admission, a brief medical-surgical history (e.g., previous surgeries or illnesses), allergies, current medication (prescribed and over the counter), the patient’s perceptions about illness or hospitalization, and a review of health risk factors?

Answer 21

History

Question 22

If not included on a separate form, where are the physical assessment results of all body systems documented?

Answer 22

History

Question 23

What provides data that you use to identify and support nursing diagnoses, establish expected outcomes of care, and plan and evaluate interventions?

Answer 23

Medical Record

Question 24

___ from the record adds to your observations and assessment.

You do not need to collect ___ that is already available.

If you have reason to believe that the ___ is inaccurate, ___ should be verified and appropriate changes made to the patient’s record.

Answer 24

Information

information

Information x 2

Question 25

Legal Documentation

___ documentation is one of the best defenses against legal claims associated with nursing care.

Answer 25

Accuracy

Question 26

Legal Documentation

From a legal perspective, the purpose of ___ is to provide proof of health care provided.

Answer 26

documentation

Question 27

Legal Documentation

What should accurately and fully possess the patient’s care as well as the patient’s response to that care?

Answer 27

Documentation

Question 28

Legal Documentation

What is vital evidence in negligent practice lawsuits and considered as important as the testimony of witnesses in the courtroom?

Answer 28

Medical Record

Question 29

Legal Documentation

To limit nursing ___, as the nurse you must clearly document that individualized, goal-directed nursing care, based on the nursing assessment, was provided to a patient and that you continue to monitor for, document, and report deterioration. The record must describe exactly what happened to a patient.

Answer 29

liability

Question 30

Legal Documentation

What should be performed immediately after care is provided?

Answer 30

Charting

Question 31

Legal Documentation

Nursing care may have been excellent, but in a court of law, care not documented is care ___ ___.

Answer 31

not provided

Question 32

Legal Documentation

In the health care ___, you need to indicate all assessments, interventions, patient responses, instructions, and referrals.

Answer 32

record

Question 33

Legal Documentation

It is important to complete all documentation on appropriate forms and to be sure that patient-___ information (patient’s name and ___ number) is on every page of documentation.

Answer 33

identifying

identification

Question 34

Legal Documentation

Eight common charting mistakes that can result in malpractice:

1) failing to record pertinent health or ___ information

2) failing to record nursing ___

3) failing to record that ___ have been given

4) recording on the wrong ___

5) failing to document a discontinued ___

6) failing to record ___ reactions or changes in the patient’s ___

7) ___ orders improperly or ___ improper orders

8) ___ illegible or incomplete records

Answer 34

drug

actions

medications

chart

medication

drug, condition

transcribing x 2

writing

Question 35

Legal Guidelines for Electronic and Written Documentation

Enter only ___ and factual descriptions of a patient’s behaviour or the actions of another health care provider.

Quote all ___ statements.

Answer 35

objective

patient

Do not document retaliatory or critical comments about a patient or care provided by another health care provider. Do not enter personal opinions.

Statements can be used as evidence for nonprofessional behaviour or poor quality of care.

Question 36

Legal Guidelines for Electronic and Written Documentation

Avoid rushing to complete documentation; be sure that information is ___ and ___.

Answer 36

accurate

complete

Question 37

Legal Guidelines for Electronic and Written Documentation

Be certain entry is ___ and thorough.

A person reading your documentation needs to be able to determine that a patient received adequate care.

Answer 37

factual

Question 38

Legal Guidelines for Electronic and Written Documentation

Document as soon after the event as possible to ensure ___.

Answer 38

accuracy

Question 39

Legal Guidelines for Electronic and Written Documentation

Do not record, “physician made error”; instead, chart that “Dr. Wong was called to ___ order for analgesic.”

Include the ___ and ___ of phone call, whom you spoke with, and the ___.

Answer 39

clarify

date, time, outcome

If an order is questioned, record that clarification was sought.

If you perform an order known to be incorrect, you are just as liable for prosecution as the prescriber is.

Question 40

Legal Guidelines for Electronic and Written Documentation

Never enter ___ for someone else.

Check agency ___ for circumstances when a third party may ___ for another nurse (e.g., designated recorder for emergency situations).

Answer 40

documentation

policy

document

Document only for yourself.

You are accountable for information you enter into a patient’s record.

Question 41

Legal Guidelines for Electronic and Written Documentation

Use complete, concise descriptions of ___ and care so that documentation is objective and factual.

Answer 41

assessments

Question 42

Legal Guidelines for Electronic and Written Documentation

Avoid using generalized, empty phrases such as “status unchanged” or “had good day.”

This type of documentation is ___ and does not reflect patient assessment.

Answer 42

subjective

Question 43

Legal Guidelines for Electronic and Written Documentation

Begin each entry with the ___ and ___ and end with your ___ and ___.

Answer 43

date

time

signature

credentials

Ensures that the correct sequence of events is recorded; signature documents who is accountable for care delivered.

Do not wait until end of shift to record important changes that occurred several hours earlier; sign each entry according to agency policy (e.g., Mei Lin, LPN).

Question 44

Legal Guidelines for Electronic and Written Documentation

Avoid “___” (documenting an entry before performing a treatment or an assessment or before giving a medication).

Answer 44

precharting

Question 45

Legal Guidelines for Electronic and Written Documentation

What invites error and thus endangers the health and safety of the patient; it is also illegal and can constitute falsification of health care records?

Answer 45

Precharting

Question 46

Legal Guidelines for Electronic and Written Documentation

Document during or immediately after giving ___ or after administering a medication.

Answer 46

care

Question 47

Legal Guidelines for Electronic and Written Documentation

Once logged into a ___, do not leave ___ screen unattended.

Log out when you leave the ___.

Make sure the ___ screen is not accessible for public viewing.

Answer 47

computer x 4

Question 48

Legal Guidelines for Electronic and Written Documentation

Protect the security of your ___ for computer documentation.

Answer 48

password

Question 49

Legal Guidelines for Written Documentation

Draw a ___ ___ through error; write “___,” above it, and sign your ___ or ___ and ___ it.

Then record note correctly.

Answer 49

single line

error

name

intials

date

Do not erase, apply correction fluid to, or scratch out errors made while recording.

Charting becomes illegible: it may appear as if you were attempting to hide information or deface record.

Question 50

Legal Guidelines for Written Documentation

Chart consecutively, line by line; if space is left, draw a line ___ through it and place your ___ and ___ at the end.

Answer 50

horizontally

signature

credentials

Do not leave blank spaces or lines in a written nurse’s progress notes.

Allows another person to add incorrect information in open space.

Question 51

Legal Guidelines for Written Documentation

Record all entries legibly and in black ___.

Answer 51

ink

Do not use felt-tip pens or erasable ink.

llegible entries can be misinterpreted, thereby causing errors and lawsuits; ink from felt-tip pens can smudge or run when wet and may destroy documentation; erasures are not permitted in clinical documentation; black ink is more legible when records are photocopied or scanned.

Question 52

Legal Guidelines for Written Documentation

Never use ___ to document in a written clinical record.

Never ___ entries or use correction fluid.

To indicate an error in written documentation, place a ___ ___ through the inaccurate information and write your ___ with ___ at the end of the text that has been crossed out.

Answer 52

pencil

erase

single line, signature, credentials

Question 53

What shows how health care agencies have used their financial resources?

Answer 53

Patient Care Record

Question 54

What information helps the nurse evaluate the quality and appropriateness of care when regularly reviewed?

Answer 54

Patient Records

This audit may be either a review of care received by discharged patients or an evaluation of care currently being given.

Question 55

Which teams often contain members from across the organization and normally perform the self-assessment requirements of Accreditation Canada?

Answer 55

Auditing

Question 56

Nurses or interdisciplinary members of a committee monitor or review records throughout the year to determine the degree to which quality ___ standards are met.

Deficiencies are explained to the nursing staff so that corrections in policy or practice can be made.

Answer 56

improvement

Question 57

Where can statistical data relating to the frequency of clinical disorders, complications, use of specific medical and nursing therapies, recovery from illness, and deaths can be gathered?

Answer 57

Patient Records

Question 58

Some data collection activities may be part of the quality ___ practices at an agency, whereas other activities may be actual clinical research studies.

Answer 58

improvement

Question 59

Different types of ___ must be secured before a researcher can review patient records for any type of research study or data analysis.

Answer 59

permission

The researcher must be sure that the data collection and analysis adhere to provincial, territorial, and agency policies.

Question 60

What can one read to learn the nature of an illness and an individual’s response?

Answer 60

Patient Care Record

Question 61

What contains a variety of information, including diagnoses, signs and symptoms of disease, successful and unsuccessful therapies, diagnostic findings, and patient behaviours?

Answer 61

Patient Record

Question 62

No two patients have identical records, but in the course of clinical training, nursing and other health care students review records of patients who have similar health problems to identify ___ of information and anticipate the type of care required for a patient.

Answer 62

patterns

Question 63

Paper records are ___ oriented, with a separate record for each patient visit to a health care agency.

Key information such as patient allergies, current medications, and complications from treatment are sometimes lost from one ___ of care (e.g., hospitalization or clinic visit) to the next, jeopardizing a patient’s safety.

Answer 63

episode x 2

Question 64

To enhance communication among health care providers and thus patient safety, Canadian Health Infoway had a mandate to partner with jurisdictions for the development and implementation of an ___ ___ ___ (___) to support effective health care delivery for Canadians.

Answer 64

electronic health record (EHR)

Question 65

Although the terms ___ ___ ___ (___) and ___ ___ ___ (___) frequently are used interchangeably in practice, there are differences between them.

Answer 65

Electronic Health Record (EHR)

Electronic Medical Record (EMR)

Question 66

What is a digital version of patient data that is found in traditional paper records?

Answer 66

Electronic Health Record (EHR)

Question 67

What term is used increasingly to refer to a longitudinal (lifetime) record of all health care encounters for an individual patient?

Answer 67

Electronic Health Record (EHR)

Question 68

What is the legal record that describes a single encounter or visit created in hospitals and outpatient health care settings?

Answer 68

Electronic Medical Record (EMR)

Question 69

What is the source of data for the Electronic Health Record (EHR)?

Answer 69

Electronic Medical Record (EMR)

Question 70

To meet agreed-on standards, Electronic Health Records (EHR) are expected to have the following attributes or components:

• Provide a longitudinal or ___ patient record by linking all patient data from previous health care encounters
• Include a ___ list indicating current clinical ___ for each health care encounter, the number of occurrences associated with all past and current ___, and the current status of each problem

Answer 70

lifetime

problem, problems x 2

Question 71

To meet agreed-on standards, Electronic Health Records (EHR) are expected to have the following attributes or components:

• Require the use of accepted, standardized measures to evaluate and record health status and functional levels
• Provide a method for ___ the clinical reasoning or rationale for diagnoses and conclusions that allows clinical decision making to be tracked by all providers who access the record

Answer 71

documenting

Question 72

To meet agreed-on standards, ___ ___ (___) are expected to have the following attributes or components:

• Support confidentiality, privacy, and audit trails
• Provide continuous access to authorized users at any time
• Allow multiple health care providers access to customized views of patient data at the same time

Answer 72

Electronic Health Records (EHR)

Question 73

To meet agreed-on standards, ___ ___ (___) are expected to have the following attributes or components:

• Support links to local or remote information resources such as databases using the Internet or intranet resources based within an organization
• Support the use of decision analysis tools
• Support direct entry of patient data by physicians
• Include mechanisms for measuring the cost and quality of care
• Support existing and evolving clinical needs by being flexible and expandable

Answer 73

Electronic Health Records (EHR)

Question 74

The promise of the ___ ___ (___) is twofold: (1) making a positive impact on the quality of patient care through interprofessional collaboration with improved data availability and information synthesis, and (2) improving patient safety through the use of clinical decision support.

Answer 74

Electronic Health Records (EHR)

Question 75

What provides access to a patient’s health record information at the time and place that clinicians need it?

Answer 75

Electronic Health Records (EHR)

Question 76

What has a unique feature to integrate all patient information into one record, regardless of the number of times a patient enters a health care system?

Answer 76

Electronic Health Records (EHR)

Question 77

What includes results of diagnostic studies that may include diagnostic images (e.g., X-ray film or ultrasound images) and decision support software programs?

Answer 77

Electronic Health Records (EHR)

Question 78

What has an unlimited number of patient records that can be stored so health care providers can access clinical data to identify quality issues, link interventions with positive outcomes, and make evidence-informed decisions?

Answer 78

Electronic Health Records (EHR)

Question 79

Here is an example of how an ___ ___ ___ (___) works:

A patient with a complex medical history sees multiple specialists to manage his or her health, such as an endocrinologist to address diabetes, a pulmonologist to manage emphysema, and a cardiologist to manage heart failure and atrial fibrillation.

Each of these providers is able to access patient data from the ___ ___ ___ (___) at the same time.

Answer 79

Electronic Health Records (EHR)

Electronic Medical Records (EHR)

Question 80

___ documentation within an Electronic Health Records (EHR) facilitates interprofessional communication; helps to meet professional, regulatory, and legal requirements; and aids in quality improvement efforts and health care research.

Answer 80

Accurate

Question 81

What do members of the health care team use to improve continuity of health care from one episode of illness to another?

Answer 81

Electronic Health Records (EHR)

Question 82

What includes tools to guide and critique medication administration and basic decision-support tools such as physician order sets and interdisciplinary treatment plans?

Answer 82

Electronic Health Records (EHR)

Question 83

What holds key advantages for nursing including a means for nurses to compare current clinical data about a patient with data from previous health care encounters and to maintain an ongoing record of health education provided to a patient and the patient’s response to that information?

Answer 83

Electronic Health Records (EHR)

Question 84

Regardless of whether documentation is entered electronically or on paper, each member of the health care team needs to document patient information in an ___, ___, ___, and effective manner to develop and maintain an effective, organized, and comprehensive plan of care.

Answer 84

accurate

timely

concise

Question 85

When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are ___, and delays or omissions in care often occur.

Answer 85

repeated

Question 86

Whether the transfer of patient information occurs through verbal reports, written documents, or electronic transfer, nurses must follow certain principles to maintain ___ of information.

Answer 86

confidentiality

Question 87

Nurses are ___ and ethically obligated to keep information about patients confidential.

Answer 87

legally

Question 88

The nurse must not share information with other patients or ___ care team members who are not caring for a patient.

Answer 88

health

Question 89

Patients have the ___ to request copies of their medical records and read the information.

Answer 89

right

Question 90

Each institution has policies that describe how medical records are shared with patients or other people who request them.

In most situations, patients are required to give ___ permission for release of medical information.

Answer 90

written

Question 91

Sometimes nurses use health care records for data gathering, research, or continuing education.

As long as a nurse uses a record as specified and ___ is granted, this is permitted.

Answer 91

permission

Question 92

When you are a student in a clinical setting, ___ and compliance with Personal Information Protection and Electronic Documents Act (PIPEDA) are part of professional practice. You can review your patients’ medical records only for information needed to provide safe and effective patient care.

Answer 92

confidentiality

When you are assigned to care for a patient, you need to review the patient’s medical record and plan of care. You do not share this information with classmates (except for clinical conferences) and do not access the medical records of other patients on the unit. Access to EHRs is traceable through user log-in information. Not only is it unethical to view medical records of other patients, but breaches of confidentiality lead to disciplinary action by employers and dismissal from work or nursing school.

Question 93

To protect patient ___, ensure that written or electronic materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information).

Answer 93

confidentiality

Question 94

Never print material from an ___ ___ ___ (___) for personal use.

Answer 94

electronic health record (EHR)

Question 95

A breach of ___ is often a careless rather than a deliberate act.

Answer 95

confidentiality

Question 96

Students need to make sure that patient-identifiable information (e.g., files, stickers, information in notebooks, worksheets) is not taken home and that it is disposed of correctly in a secure bin for ___.

Answer 96

shredding

Question 97

Breaches of ___ are accessing information not related to your duties, discussing patient information in an inappropriate area, such as in an elevator or on public transport, revealing to a caller confidential patient or co-worker details, emailing patient information through a public network such as the Internet, and leaving confidential material in a public area.

Answer 97

confidentiality

Question 98

Even after you are no longer on placement at an agency, you are obligated to maintain the ___ of patients and co-workers at that agency.

Answer 98

confidentiality

Question 99

What includes individually identifiable health information such as demographic data; facts that relate to an individual’s past, present, or future physical or mental health condition; provision of care; and payment for the provision of care that identifies the individual?

Answer 99

Personal Health Information (PHI)

Question 100

What is the federal legislation that protects personal information, including health information?

Answer 100

Personal Information Protection and Electronic Documents Act (PIPEDA)

Question 101

Who delineates how private-sector organizations may collect, use, or disclose personal information in the course of commercial activities?

Answer 101

Personal Information Protection and Electronic Documents Act (PIPEDA)

Question 102

Which safety mechanism logs a user off a computer system after a specified period of inactivity?

Answer 102

Automatic Sign-Off

Question 103

Which combination of hardware and software protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information?

Answer 103

Firewall

Question 104

Which security measure includes placing computers or file servers in restricted areas or using privacy filters for computer screens visible to visitors or others without access?

Answer 104

Physical

Question 105

Which form of security has limited benefit, especially if an organization uses mobile wireless devices such as notebooks, tablets, personal computers (PCs), and smart phones?

Answer 105

Physical

These devices are easily misplaced or lost, falling into the wrong hands. Some organizations use motion detectors or alarms with these devices to help prevent theft.

Question 106

Access or log-in codes along with ___ are frequently used for authenticating authorized access to electronic records.

Answer 106

passwords

Question 107

What is a collection of alphanumeric characters that a user types into a computer before accessing a program after the entry and acceptance of an access code or user name?

Answer 107

Password

Question 108

___ passwords use combinations of letters, numbers, and symbols that are difficult to guess.

Answer 108

Strong

Question 109

When using a health care agency computer system, it is essential that you do not share your computer ___ with anyone under any circumstances.

Answer 109

password

Question 110

A good system requires frequent, random changes in personal ___ to prevent unauthorized people from tampering with records.

Answer 110

passwords

Question 111

What does not appear on the computer screen when it is typed, nor should it be known to anyone but the user and information system administrators?

Answer 111

Password

Question 112

Most health care personnel are only given ___ to patients in their work area.

Some staff (e.g., administrators or risk managers) have authority to ___ all patient records.

To protect patient privacy, health care agencies track who ___ patient records and when they ___ them.

Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately ___ patient information.

Answer 112

access x 2

accesses

access x 2

Question 113

You print a copy of a nursing activities work list to use as a day planner while providing patient care. You refer to information on the list and write notes to enter later into the computer. Information on the list is ___ ___ ___ (___); you do not leave it out for view by unauthorized people.

Answer 113

Personal Health Information (PHI)

Question 114

Destroy (e.g., ___) anything that is printed when the information is no longer needed.

Answer 114

shred

Question 115

Nursing students must write down patient data needed for clinical paperwork directly from a patient’s medical record on the computer screen or the physical chart.

When writing patient data onto forms or including it in papers written for nursing courses, you need to ___-___ all patient data.

Do not remove patient information that is printed out from a clinical agency.

If you need to remove printed information from a clinical setting, ___-___ all personal health information (PHI), keep the documents secure, and destroy documents by ___ or disposing of them in a locked receptacle as soon as possible.

Answer 115

de-identify x 2

shredding

Question 116

Historically the primary sources for inadvertent, unauthorized disclosure of ___ ___ ___ (___) occurred when information was printed from a patient record and/or faxed to other health care providers.

Answer 116

personal health information (PHI)

Question 117

Nurses need to destroy all papers containing personal health information (PHI) (e.g., social insurance number, date of birth or age, patient’s name or address) immediately after using or ___ them.

Answer 117

faxing

Question 118

Most agencies have ___ or locked receptacles for ___ and incineration.

Answer 118

shredders

shredding

Question 119

Some nurses work in settings where they are responsible for erasing files from a computer hard drive that contain calendars, surgery or diagnostic procedure schedules, or other daily records that contain ___ ___ ___ (___).

Answer 119

personal health information (PHI)

Question 120

It is important to know and follow the disposal ___ for records in the institution where you work.

Answer 120

policies

Question 121

Health care facilities and departments have policies for the use of ___ machines, which specify the types of information that can be ___, allowable recipients of the information, where information is sent, and the process used to verify that information was sent to and received by the appropriate person(s).

Answer 121

fax

faxed

Question 122

Nurses should ___ only the amount of information that is requested or required for immediate clinical needs.

Answer 122

fax

Question 123

The following are some steps to take to enhance fax security:

• Confirm that fax ___ are correct before sending to be sure that you direct information properly
• Use a ___ sheet to eliminate the need for the recipient to read the information to determine who gets it. This is especially important if a fax machine serves a number of different users.

Answer 123

numbers

cover

Question 124

The following are some steps to take to enhance fax security:

• ___ at both ends before data transmission to verify that source and destination are correct. Use the cover sheet to list intended recipient(s), the sender, and the phone and fax numbers. Verify the fax number on the transmittal confirmation sheet.
• Use programmed ___-dial keys to eliminate the chance of a dialing error and misdirected information.

Answer 124

Authenticate

speed

Question 125

The following are some steps to take to enhance fax security:

• Use the ___ feature on the fax machine. Encoding transmissions makes it impossible to read confidential information without the ___ key.
• Place fax machines in a ___ area and limit machine access to designated individuals
• ___ fax transmissions. This feature is often available electronically on the machine.

Answer 125

encryption x 2

secure

Log

Question 126

What takes place through the patient’s record or chart and reports?

Answer 126

Communication

Question 127

What is a confidential, permanent legal document of information relevant to a patient’s health care?

Answer 127

Record

Chart

Question 128

All health records contain the following information:

• Patient ___ and demographic data
• Informed ___ for treatment and procedures
• Advance ___

Answer 128

identification

consent

directives

Question 129

All health records contain the following information:

• Admission nursing ___
• Nursing ___ or problems and the nursing or interdisciplinary care plan
• Record of nursing care treatment and evaluation
• Medical ___

Answer 129

history

diagnoses

history

Question 130

All health records contain the following information:

• Medical diagnosis
• Therapeutic orders
• Progress notes for various health care providers
• Reports of ___ examinations
• Reports of diagnostic studies
• Record of patient and family education
• Summary of operative procedures
• ___ plan and summary

Answer 130

physical

Discharge

Question 131

What are oral, written, or audiotaped exchanges of information between caregivers?

Answer 131

Reports

Question 132

What are commonly compiled by nurses during change-of-shifts, telephone, transfer, and incident or occurrence?

Answer 132

Reports

Question 133

A physician or nurse practitioner may call a nursing unit to receive a verbal ___ on a patient’s condition and progress.

A laboratory submits a written ___ about the results of diagnostic tests.

Answer 133

report x 2

Question 134

Team members communicate information through discussions or ___.

For example, a discharge planning ___ often involves members of several disciplines (e.g., nursing, social work, dietary, medicine, and physiotherapy) who meet to discuss the patient’s progress toward established discharge goals.

Answer 134

conferences

conference

Question 135

Which form of discussion includes one professional caregiver giving formal advice about the care of a patient to another caregiver?

Answer 135

Consultations

Question 136

A nurse caring for a patient with a chronic wound may need a ___ with a wound care specialist.

Answer 136

consultation

Question 137

What is an arrangement for services by another care provider?

Answer 137

Referral

Question 138

Referrals, consultations, and conferences must be ___ in a patient’s permanent record so that all caregivers can plan care accordingly.

Answer 138

documented

Question 139

Nursing documentation too often consists of a list of ___ performed and the production of quality documentation can be a challenge for nurses.

Answer 139

tasks

Question 140

What are the six important characteristics of quality documentation?

Answer 140

A - Accurate

Cool - Complete

Current - Cat

Found - Factual

Oatmeal - Organized

Cookies - Complies (with standards set by Accreditation Cananda and by the provincial or territorial regulatory bodies)

Question 141

It is easier to maintain the six important chracteristics of quality documentation if you continually seek to express ideas clearly and succinctly by:

• Sticking to the ___
• Writing in ___ sentences
• Using ___, short words
• Avoiding the use of jargon or ___

Answer 141

facts

short

simple

abbreviations

Question 142

Which record type contains characteristics like descriptive, objective information about what a nurse sees, hears, feels, and smells?

Answer 142

Factual

Question 143

Which record type avoids vague terms such as appears, seems, or apparently?

Answer 143

Factual

These words suggest that you are stating an opinion; they do not communicate facts accurately and do not inform another caregiver of the details regarding the behaviours exhibited by the patient.

Question 144

Which data type is obtained through direct observation and measurement (e.g., “BP 80/50, patient diaphoretic, heart rate 102 and regular”)?

Answer 144

Objective

Question 145

Which documentation type includes the observations of the patient’s behaviours?

Answer 145

Objective

Question 146

Which data type, in the record, is what the patient says?

Answer 146

Subjective

Question 147

Which data type is recoreded by documenting the patient’s exact words within quotation marks wherever possible?

Answer 147

Subjective

Question 148

Include ___ data to support ___ data so your documentation is as descriptive as possible.

Answer 148

objective

subjective

Question 149

Instead of documenting “the patient seems anxious,” provide ___ signs of anxiety and document the patient’s statement about the feeling(s) experienced (e.g., “the patient’s pulse rate is 110/beats/min, respiratory rate is slightly laboured at 22 breaths/min, and the patient states ‘I feel very nervous’ ”).

Answer 149

objective

Question 150

What does the use of exact measurements establish and helps the nurse determine if a patient’s condition has changed in a positive or negative way?

Answer 150

Accuracy

Question 151

A description such as “intake, 360 mL of water” is more ___ than “Patient drank an adequate amount of fluid.”

Answer 151

accurate

Question 152

Documenting that an abdominal wound is “5 cm in length without redness, drainage, or edema” is more ___ than “large wound healing well.”

Answer 152

accurate

Documentation of concise data should be clear and easy to understand. Avoid the use of unnecessary words and irrelevant detail. For example, the fact that the patient is watching TV is only necessary when this activity is significant to the patient’s status and plan of care.

Question 153

Most health care institutions develop a list of standard ___, symbols, and acronyms to be used by all members of the health care team in documenting or communicating patient care and treatment.

Answer 153

abbreviations

Question 154

Approved ___ and acronyms vary, depending on the type of facility (i.e., long-term versus acute care facility).

Answer 154

abbreviations

Question 155

Use of an institution’s accepted ___, symbols, and system of measures (e.g., metric) ensures that all staff members use the same language in their reports and records.

Answer 155

abbreviations

Question 156

Always use ___ carefully to avoid misinterpretation.

For example, “od” (every day) can be misinterpreted to mean “O.D.” (right eye).

Answer 156

abbreviations

Question 157

If ___ are confusing, to minimize errors, you should spell terms out in their entirety.

Answer 157

abbreviations

Question 158

The Institute for Safe Medication Practices (ISMP) has published an extensive list of error-prone abbreviations, symbols, and dose designations that health care institutions need to consider adding to their “___ ___ ___” lists.

Answer 158

do not use

Question 159

Write “___” instead of “U”, always using a zero before a decimal point in a decimal fraction (e.g., “0.25 mg”), and not writing a zero alone after a decimal point (e.g., writing “5 mg,” not “5.0 mg”).

Answer 159

unit

Question 160

Correct spelling demonstrates a level of competency and attention to detail.

Many terms can easily be misinterpreted (e.g., dysphagia and dysphasia).

Some spelling errors can also result in serious treatment errors (e.g., the names of certain look alike-sound alike medications, such as morphine and hydromorphone, are similar).

___ medication names carefully to ensure that patients receive the correct medication.

Answer 160

Transcribe

Question 161

Record entries must be ___, and a method for ___ the authors of entries must be in place.

Answer 161

dated

identifying

Question 162

Each entry in a patient’s record ends with the caregiver’s full name or ___ and credentials/title/role such as “Holly Lee, LPN.”

If ___ are used in a signature, the full name and credentials/title/role of the individual need to be documented at least once in the medical record to allow others to readily identify the individual.

Answer 162

initials

Question 163

As a nursing student, enter your full name and ___ ___ (___) abbreviation.

Answer 163

student nurse (SN)

Henri Gauthier, SN

The abbreviation for student nurse varies between SN/SPN for student nurse/student practical nurse or NS/PNS for nursing student/practical nursing student.

Question 164

Include your ___ institution when required by agency policy.

Answer 164

educational

Question 165

Records must reflect ___ during the time frame of the entry.

Answer 165

accountability

Question 166

What is best accomplished when you chart only your own observations and actions?

Answer 166

Accountability

Question 167

What holds you accountable for information recorded?

Answer 167

Signature

Question 168

You should refer to agency ___ before making late entries, correcting errors, or completing an omission.

Answer 168

policy

Question 169

___ entries are often documented by writing the current date and time in the next available space as close to the ___ entry as possible and writing “___ entry for [date and shift].”

Answer 169

Late

late x 2

Question 170

For adding information to an existing entry, using the current date and time in the next space and adding “___ to note of [date and time of prior note]” is a good practice.

Answer 170

addendum

Question 171

The information within a recorded entry or a report must be ___, containing appropriate and essential information.

Answer 171

complete

Question 172

It is important to document all nursing interventions, such as education and psychosocial support, as this information and the ___ of these interventions are not often recorded in nursing documentation.

Answer 172

outcomes

An example of a thorough nurse’s note is as follows:

1915 hrs: Patient verbalizes sharp, throbbing pain localized along lateral side of right ankle, beginning approximately 15 minutes after twisting his foot on the stairs at 1700. Patient rates pain as 8 on a scale of 0–10. Pain increased with movement, slightly relieved with elevation. Pedal pulses equal bilaterally. Right ankle circumference 1 cm larger than left. Bilateral lower extremities warm, pale pink, skin intact, responds to tactile stimulation, capillary refill less than 3 seconds. Ice applied. Percocet 2 tabs (PO) given for pain. Patient states pain somewhat relieved with ice, rates pain as 6 on a scale of 0–10. Dr. P. Yoshida notified. Lee Turno, RN.

1945 hrs: States pain was somewhat relieved with ice and now rates pain as a 3 on a scale of 0–10. States, “The pain medication really helped.” Lee Turno, RN

Question 173

Frequently you will use ___ sheets or graphic records to document routine activities such as daily hygiene care, vital signs, and pain assessments.

Describe these data in greater detail when they are relevant, such as when a change in functional ability or status occurs.

For example, if your patient’s blood pressure, pulse, and respirations are elevated above expected values following a walk down the hall, document additional description about the patient’s status and response to the walk in the appropriate place in the medical record (e.g., nurse’s ___).

Answer 173

flow

notes

Question 174

___ entries are essential to the patient’s ongoing care.

Documentation should occur during or as soon as possible after the incident or intervention, and events should be described ___ to reflect a clear record of exactly what happened.

Answer 174

Timely (Current)

chronologically

Question 175

To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near the patient’s ___ to facilitate immediate documentation of information as it is collected.

Answer 175

bedside

Question 176

Which sheets are a means of entering current information quickly?

Answer 176

Flow

Question 177

Portable electronic workstations or secure wall cabinets in patient rooms help ensure that patient ___ is maintained.

Answer 177

confidentiality

Question 178

Nurses often keep ___ on a worksheet when caring for several patients, making ___ as the care occurs to ensure that entries recorded later in the record are accurate.

Answer 178

notes x 2

Question 179

The following activities and findings should be communicated at the time of occurrence:

• ___ signs
• ___ assessment
• ___ of medications and treatments
• ___ for diagnostic tests or surgery, including preoperative checklist
• ___ in patient’s status and who was notified (e.g., nurse practitioner, physician, manager, patient’s family)
• Admission, transfer, discharge, or ___ of a patient
• Treatment for a sudden change in patient’s status
• Patient’s ___ to treatment or intervention

Answer 179

Vital

Pain

Administration

Preparation

Change

death

response

Question 180

Which time do most health care agencies use?

Answer 180

Military

Question 181

Whic time is a 24-hour system that avoids misinterpretation of “a.m.” and “p.m.”?

Answer 181

Military

Question 182

Instead of two 12-hour cycles in standard time, the military clock is one ___-hour time cycle.

Answer 182

24

Question 183

Which clock ends with midnight (2400) and begins with 1 minute after midnight (0001)?

Answer 183

Military

10:22 a.m. is 1022 military time;
1:00 p.m. is 1300 military time

Question 184

As a nurse, you want to communicate information in a logical order.

For example, an ___ note describes the patient’s pain, the nurse’s assessment and interventions, and the patient’s response.

Answer 184

organized

Question 185

To write notes about complex situations in an ___ manner, think about the situation and make notes of what is to be included before you begin to write in the permanent legal record.

Answer 185

organized

Question 186

What needs to follow standards set by Accreditation Canada and by provincial or territorial regulatory bodies to maintain institutional accreditation and to decrease the risk of liability?

Answer 186

Documentation

Question 187

Current standards require that all patients who are admitted to a health care institution undergo physical, psychosocial, environmental, and self-care ___; receive patient ___; and be provided ___ planning.

Answer 187

assessments

education

discharge

Question 188

Criteria for standards stress the importance of evaluating patient ___, including the patient’s response to treatments, teaching, or preventive care.

Answer 188

outcomes

Question 189

The nursing service department of each health care ___ selects a method of documenting patient care.

The method reflects the philosophy of the nursing department and incorporates the ___ of care.

Because the ___ process shapes a nurse’s approach and direction of care, effective documentation also reflects the ___ process.

Answer 189

agency

standards

nursing x 2

Question 190

Examples of a Nursing Progress Note Written in Different Formats

Which documentation method is used below?:

Patient stated, “I’m worried about the surgery. Last time I had a lot of pain when I got out of bed.” Discussed importance of postoperative ambulation and demonstrated turning, coughing, deep-breathing (TCDB) exercises. Patient set post­operative pain-rating goal at 4 on scale of 0 to 10. Discussed analgesic plan of care and reassured that analgesics will be offered around the clock as ordered. Encouraged to tell nursing staff as soon as possible if pain is not relieved. Provided with teaching booklet on postoperative care. Stated, “I feel less anxious about my pain now.” Verbalized understanding of the importance of postoperative ambulation and confidence in the plan of care.

Answer 190

Narrative

Question 191

Examples of a Nursing Progress Note Written in Different Formats

Which documentation method is used below?:

“I’m worried about the surgery. Last time I had a lot of pain when I got out of bed.”

Asking multiple questions about how postoperative pain will be addressed.

Anxiety related to perceived threat of postoperative pain as evidenced by statement of prior experience with uncontrolled postoperative pain.

Explain routine postoperative analgesic plan of care. Encourage to inform nursing staff as soon as possible if pain is not relieved. Explain rationale for early postoperative ambulation and demonstrate TCDB exercises. Provide teaching booklet on postoperative nursing care.

Answer 191

SOAP (Subjective - Objective -Assessment - Plan)

Question 192

Examples of a Nursing Progress Note Written in Different Formats

Which documentation method is used below?:

Anxiety related to perceived threat of postoperative pain as evidenced by statement of prior experience with uncontrolled postoperative pain.

Explained importance of postoperative ambulation and demonstrated TCDB exercises. Described analgesic plan of care. Encouraged to inform nursing staff as soon as possible if pain is not relieved. Provided teaching booklet on postoperative nursing care.

Stated, “I feel less anxious about postoperative pain now” and performed return demonstration of TCDB exercises correctly.

Answer 192

PIE (Problem - Intervention - Evaluation)

Question 193

Examples of a Nursing Progress Note Written in Different Formats

Which coumentation method is used below?:

Patient stated, “I’m worried about the surgery. Last time I had a lot of pain when I got out of bed.” Asked frequent questions about postoperative pain management.

Discussed importance of postoperative ambulation and demonstrated TCDB exercises. Described postoperative analgesic plan of care that is in place. Provided teaching booklet on postoperative nursing care.

Demonstrated TCDB exercises correctly. States, “I feel better knowing how my pain will be treated.”

Answer 193

Focus Charting DAR (Data - Action -Response) Note

Question 194

Which documentation method is traditionally used to record patient assessment and nursing care provided?

Answer 194

Narrative

Question 195

What is simply the use of a storylike format to document information?

Answer 195

Narrative

Question 196

In an electronic nursing information system, which documentation method is accomplished through use of free text entry or menu selections?

Answer 196

Narrative

Question 197

Which documentation method tends to be time consuming and repetitious and requires the reader to sort through a lot of information to locate desired data?

Answer 197

Narrative

Question 198

Which doucmentation method provides better detail of individual patient assessment findings and/or complex patient situations?

Answer 198

Narrative

Question 199

What do physicians and other health care providers review for details about changes in a patient’s condition?

Answer 199

Doucmentation

Question 200

One of the limitations of electronic documentation is the limited use of ___ documentation.

Some areas of the electronic medical record (EMR) are designed to use multiple checkboxes or drop-down lists, which some believe may not adequately convey the details of significant events that result in a change in patient condition

Answer 200

narrative

Question 202

Which medical record is a system of organizing documentation to place the primary focus on patients’ individual problems?

Answer 202

Problem - Oriented

Problem - Oriented Medical Record (POMR)

Question 203

Which medical reocord system is organized by problem or diagnosis; where each member of the health care team contributes to a single list of identified patient problems?

Answer 203

Problem - Oriented

Problem - Oriented Medical Record (POMR)

This assists in coordinating a common plan of care.

Question 204

What are the four major sections of the problem - oriented medical record (POMR)?

Answer 204

Daring - Database

Pirates - Problem list

Capture - Care Plan

Prizez - Progress Notes

Question 205

Which section contains all available assessment information pertaining to the patient (e.g., history and physical examination, nursing admission history and ongoing assessment, physiotherapist’s assessment, laboratory reports, and radiological test results)?

Answer 205

Database

Question 206

What provides the foundation for identifying patient problems and planning care?

Answer 206

Database

Question 207

What is revised as new data become available?

Answer 207

Database

Question 208

What accompanies patients through successive hospitalizations or clinic visits?

Answer 208

Database

Question 209

What do health care team members make after indteifying problems and analyzing data?

Answer 209

Problems List

Question 210

The problem list includes a patient’s physiological, psychological, social, cultural, spiritual, developmental, and environmental needs.

Team members list the problems in ___ order and file the list in the front of the patient’s record to serve as an organizing guide for patient care.

Team members add and date new problems as they arise.

When a problem has been resolved, the text of that problem is highlighted, or lined out, and the date is recorded.

Answer 210

chronological

Question 211

What involves disciplines in a patient’s care for each problem?

Answer 211

Care Plan

Question 212

Nurses document the plan of care in a variety of formats; generally all of these formats include nursing ___, expected ___, and ___.

Answer 212

diagnoses

outcomes

interventions

Question 213

Where do health care team members monitor and record the progress made toward resolving a patient’s problems?

Answer 213

Progress Notes

Question 214

What does the acronym SOAP stands for?

Answer 214

Subjective

Objective

Assessment

Plan

Question 215

Which data is verbalizations of the patient?

Answer 215

Subjective

Question 216

Which data is measured and observed?

Answer 216

Objective

Question 217

What is diagnosis based on the data?

Answer 217

Assessment

Question 218

What is what caregiver plans to do?

Answer 218

Plan

Question 219

What do the “I” and “E”, added to SOAP(IE) in some institutions, represent?

Answer 219

Intervention

Evalulation

Question 220

Which note format is similar to that of the nursing process?

Answer 220

SOAPIE

The nurse collects data about a patient’s problems, draws conclusions, develops a plan of care, and then evaluates the outcome(s).

Each SOAP note is numbered and titled according to the problem on the list that it addresses.

Question 221

What does PIE stand for?

Answer 221

Problem

Intervention

Evalulation

Question 222

Which note format is similar to SOAP charting in its problem-oriented nature, but originated in nursing practice rather than medical records?

Answer 222

PIE

Question 223

Which format simplifies documentation by unifying the care plan and progress notes?

Answer 223

PIE

Question 224

PIE notes differ from SOAP notes in that the narrative does not include ___ information.

Answer 224

assessment

A nurse’s daily assessment data appear on flow sheets, preventing duplication of data.

The narrative note includes the problem, the intervention, and the evaluation.

The PIE notes are numbered or labelled according to the patient’s problems.

Resolved problems are dropped from daily documentation after the nurse’s review.

Continuing problems are documented daily.

Question 225

What is DAR?

Answer 225

Data

Action

Response

Question 226

What is both subjective and objective?

Answer 226

Data

Question 227

What is nursing intervention?

Answer 227

Action

Question 228

What is the evaluation of effectiveness of the action in a patient?

Answer 228

Response

Question 229

Which note method addresses patient concerns: a sign or symptom, condition, nursing diagnosis, behaviour, significant event, or change in a patient’s condition?

Answer 229

DAR

Documentation in this format follows the nursing process.

Question 230

Which format enables nurses to broaden their thinking to include any patient concerns, not just problem areas?

Answer 230

DAR

Question 231

Which charting incorporates all aspects of the nursing process, highlights a patient’s concerns, and can be integrated into any clinical setting?

Answer 231

Focus

Question 232

In which record are patient’s chart organized so that each discipline (e.g., nursing, medicine, social work, respiratory therapy) has a separate section in which to record data?

Answer 232

Source

Question 233

Which record system allows caregivers to easily locate the proper section in which to make entries?

Answer 233

Source

Question 234

Which record has a disadvantage because details about a specific problem may be distributed throughout the record?

Answer 234

Source

Question 235

Which record system is decsribe below?:

In the case of a patient with bowel obstruction, the nurse describes in the nurses’ notes the character of abdominal pain and the use of relaxation therapy and analgesic medication.

In a separate section of the record, the physician’s notes describe the progress of the patient’s condition and the plan for surgery.

The findings of X-ray examinations that reveal the location of the bowel obstruction are in the test results section of the record.

Answer 235

Source

Question 236

The nursing notes or interdisciplinary progress notes section is where nurses enter a ___ description of nursing care and the patient’s response.

It is also a section for documenting care that is provided by the physician or nurse practitioner in the nurse’s presence.

The nurse may record key diagnostic test results from other sections of the record in the nurses’ notes if they are of major importance in the care of the patient.

Answer 236

narrative

Question 237

Which note type is this?

May 24, 2018

1100 hrs: Patient states, “I’m having a hard time catching my breath.” R [Respirations], laboured at 32/min; P [pulse] 120; BP 112/70. Oxygen saturation 90% on room air. Patient alert and oriented. Patient using intercostal muscles during inspiration. Wheezes noted in both lower lobes. Chest excursion equal bilaterally. Elevated head of bed to Fowler’s position. Obtained arterial blood gas (ABG) sample at 1045. O2 (oxygen) started at 2 L/min per nasal prongs as ordered. Remained at bedside to calm patient.

Pam Haske, RN

1130 hrs: Results of ABGs reported to Dr Stein are pH 7.34; PCO2 [partial pressure of carbon dioxide] 44 mm Hg; PO2 [partial pressure of oxygen] 80 mm Hg. Patient states, “It is easier to breathe now.” R 24/min; P 96; BP 110/72. Oxygen saturation 97% on O2 at 2 L/min per nasal prongs, lips pale pink; capillary refill less than 3 seconds. Wheezing still audible on auscultation. Patient remains in high Fowler’s position.

Pam Haske, RN

Answer 237

Narrative

Question 238

The philosophy behind ___ ___ ___ (___) is that a patient meets all standards unless otherwise documented.

Answer 238

charting by exception (CBE)

Question 239

Which documentation system is still used despite its philosophy consistently raising professional concern?

Answer 239

Charting by Exception (CBE)

Question 240

Which systems incorporate standards of care, evidence-informed interventions, and clearly defined criteria for nursing assessment and documentation of “normal” findings?

Answer 240

Charting by Exception (CBE)

Question 241

What are the predefined statements used to document nursing assessment of body systems?

Answer 241

Within Defined limits (WDL) or Within Normal Limits (WNL)

Question 242

What consists of written criteria for a “normal” assessment for each body system?

Answer 242

Within Defined Limits (WDL) or Within Normal Limits (WNL)

Question 243

Which system allows nurses to select a within defined limits (WDL) statement or to choose other statements from a drop-down menu that allow descriptions of any assessment findings that deviate from the within defined limits (WDL) definition or that are unexpected?

Answer 243

Charting by Exception (CBE)

Question 244

With which system does the nurse write a progress note only when a patient’s assessment does not meet the standardized criteria for “normal” in one or more body systems?

Answer 244

Charting by Exception (CBE)

Question 245

Which model of delivering care incorporates an interdisciplinary approach to documenting patient care?

Answer 245

Case Management

Question 246

In many organizations, the standardized plan of care is summarized into ___ ___ for a specific disease or condition.

Answer 246

critical pathways

Clinical Pathways

Question 247

What is also known as clinical pathways, practice guidelines, or CareMap tools?

Answer 247

Critical Pathways

Question 248

What are interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame?

Answer 248

Critical Pathways

Question 249

What do many organizations summarize the standardized plan of care into for a specific disease or condition?

Answer 249

Critical Pathways

Question 250

Evidence-informed ___ ___ improve patient outcomes.

For example, one ___ ___ to manage pain caused by vascular-occlusive crisis in patients with sickle cell disease significantly improved the time interval between patient triage and administration of first analgesic dose and the likelihood of ketorolac administration in a pediatric emergency department.

Answer 250

critical pathways

critical pathway

Question 251

What eliminates the need for nurses’ notes, flow sheets, and nursing care plans because the document integrates all relevant information?

Answer 251

Critical Pathways

Question 252

What are unexpected occurrences, unmet goals, and interventions not specified within the clinical pathway time frame?

Answer 252

Variances

Question 253

What is present when the activities on the clinical pathway are not completed as predicted or the patient does not meet the expected outcomes?

Answer 253

Variance

Question 254

An example of a negative ___ is when a patient postoperatively develops pulmonary complications necessitating oxygen therapy and monitoring with pulse oximetry.

An example of a positive ___ is when a patient progresses more rapidly than expected (e.g., use of a Foley catheter may be discontinued a day early).

A ___ analysis is necessary to review the data for trends and for developing and implementing an action plan to respond to the identified patient problems.

Answer 254

variance x 3

Question 255

What may result from changes in the patient’s health or may occur as a result of other health complications not associated with the primary reason why the patient requires care?

Answer 255

Variances

Question 256

You are using a critical pathway for “Routine Postoperative Care” for a 56-year-old man who had abdominal surgery yesterday.

One of the expected outcomes for postoperative day 1 on the critical pathway document is “Afebrile with lungs clear bilaterally.”

This patient has an elevated temperature, his breath sounds are decreased bilaterally in the bases of both lungs, and he is slightly confused.

The following is an example of how you document this ___ on the pathway:

“Breath sounds diminished bilaterally at the bases. T 37.8° C; P 92; R 28/min; oxygen saturation 84% on room air. Daughter states he is “confused” and did not recognize her when she arrived a few minutes ago. Oxygen started at 2 L/min via nasal prongs. Head of bed elevated. Oxygen saturation improved to 92% after 5 minutes. Dr. P. Yoshida notified of change in status. Daughter remains at bedside.”

Answer 256

variance

Question 257

What is completed when a patient is admitted to a nursing care unit and guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems?

Answer 257

History

Question 258

Which component of history forms provide baselines that can be compared with changes in the patient’s condition?

Answer 258

Data

Question 259

Acute and critical care nurses commonly use ___ sheets and graphic records to document physiological data and routine care.

Answer 259

flow

Question 260

Which forms, within a computerized documentation system, allow the nurse to quickly and easily enter assessment data about a patient, such as vital signs, admission and/or daily weights, and percentage of meals eaten?

Answer 260

Flow Sheets

Question 261

What facilitates documentation of the provision of routine, repetitive care, such as hygiene measures, ambulation, and safety and restraint checks?

Answer 261

Flow Sheets

Question 262

Any occurrence on a flow sheet that is unusual or represents a significant change in a patient’s condition is explained in detail in a ___ ___.

For example, if a patient’s blood pressure becomes dangerously high, you first complete and record a focused assessment and then document the action taken in a ___ ___.

Answer 262

progress note x 2

Question 263

What is printed out for each patient during each shift to provide basic, summative information on the patient’s care?

Answer 263

Kardex

Question 264

What is continually updated and provides the nurse with a current detailed list of patient orders, treatment, and diagnostic testing?

Answer 264

Kardex

Question 265

Which plans preprinted, established guidelines used to care for patients who have similar health problems?

Answer 265

Standardized

Question 266

Which plans establish clinically sound standards of care for similar groups of patients?

Answer 266

Standardized

Question 267

Which care plans can help nurses recognize the accepted requirements of care for patients and also improve continuity of care?

Answer 267

Standardized

Question 268

Which care plans have a major disadvantage, preventing nurses from providing unique, individualized therapies for patients?

Answer 268

standardized

Standardized care plans cannot replace the nurse’s professional judgement and decision making.

In addition, care plans need to be updated on a regular basis to ensure that content is current and appropriate.

Question 269

Which planning helps ensure that a patient leaves the hospital in a timely manner with the necessary resources in place?

Answer 269

Discharge

Question 270

What information is printed out for patients and includes education about the nature of their disease process, its likely progress, and the signs and symptoms of complications?

Answer 270

Discharge

When given directly to patients, the form may be attached to pamphlets or teaching brochures.

Question 271

Which ratings determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours?

Answer 271

Acuity

Question 272

What is based on the type and number of nursing interventions (e.g., intravenous [IV] therapy, wound care, or ambulation assistance) required by a patient over a 24-hour period?

Answer 272

Acuity

Question 273

What is a classification used to compare one or more patients to another group of patients?

Answer 273

Acuity

Question 274

Which system classifies bathing patients from 1 (independent in all but one or two aspects of care; almost ready for discharge) to 5 (totally dependent in all aspects of care; requiring intensive care)?

Answer 274

Acuity

Question 275

Which ratings justify the number and qualifications of staff needed to safely care for patients?

Answer 275

Acuity

Question 276

Which health care focuses on family-centred care and forming a partnership or collaboration with the patient and the family to help the patient regain health and to help the family take over the patient’s care?

Answer 276

Home

Question 277

Which health care includes the majority of care being performed by the patient and family?

Answer 277

Home

Question 278

Which health care includes the nurse teaching and helping the patient and family achieve greater independence?

Answer 278

Home

Question 279

In which care setting is the patient the guardian of the health care record?

Answer 279

Home

Question 280

In which care setting is much of the interaction between health care providers conducted virtually by phone or fax over password-protected voice mail or secure fax lines?

Answer 280

Home

With the increasing availability of smart phones and laptop computers or tablets, home health care records can be available in multiple locations, improving accessibility to information and facilitating interprofessional collaboration.

Question 281

In which care setting is health often stable and daily documentation completed on flow sheets?

Answer 281

Long Term

Question 282

In which care setting are assessments performed weekly or monthly rather than several times a day like in acute?

Answer 282

Long Term

Question 283

Document every phone call you make to a health care provider.

Your documentation includes:

1) ___ the call was made?

2) ___ made the call (if you did not make the call)?

3) ___ was called?

4) ___ was given information?

5) ___ information was given?

6) What information was ___?

An example is as follows: “May 20, 2017 (2030 hrs): Called Dr. Morgan’s office. Spoke with Sam Thomas, RN, who will inform Dr. Morgan that Mr. Wade’s potassium level drawn at 2000 hrs was 5.9 mEq/dL. Informed that Dr. Morgan will call back after he is finished seeing his current patient. Carla Skala, RN.”

Answer 283

When

Who x 3

What

received

Question 284

What occur when a health care provider gives therapeutic orders over the phone to a registered nurse?

Answer 284

Telephone Orders (TO)

Question 285

What occur when a health care provider gives therapeutic orders to a registered nurse while they are standing in close proximity to each other?

Answer 285

Verbal Orders (VO)

Question 286

Which two orders usually occur at night or during emergencies and should be used only when absolutely necessary and not for the sake of convenience?

Answer 286

Telephone & Verbal

Question 287

For which order is it prudent to have a second person listen?

Answer 287

Telephone

Question 288

During which order do nurses use the “read-back” process and document that they did to provide evidence that the information received (such as call-back instructions and/or therapeutic orders) was verified with the provider?

Answer 288

Telephone

An example follows:

March 4, 2017 (0815 hrs) Change IV fluid to Lactated Ringer’s with potassium 20 mEq per litre to run at 125 mL/hour. TO: Dr. Knight/J. Woods, RN, read back.

The health care provider later verifies the TO or VO legally by signing it within a set time (e.g., 24 hours) as set by hospital policy.

Question 289

• Clearly determine the patient’s name, room number, and diagnosis
• ___ any prescribed orders back to the physician or health care provider
• Use clarification questions to avoid misunderstandings
• Write telephone order (“TO”) or verbal order (“VO”), including ___ and ___, ___ of patient, and the complete ___; sign the names of the ___ or other health care provider and ___
• Follow agency policies; some institutions require telephone (and verbal) orders to be reviewed and signed by ___ nurses
• The physician must co-sign the order within the time frame required by the institution (usually ___ hours)

Answer 289

Repeat

date, time, name, order, physician, nurse

2

24

Question 290

At the end of each shift, nurses report information about their assigned patients to the nurses working on the next shift. While there is an increasing awareness that high-quality handover practices are critical to ensure patient safety and continuity of care among nurses, there is very little evidence for what constitutes best practice in change-of-shift reports (Riesenberg, Leisch, & Cunningham, 2010). Various terms are used to describe this exchange of information, such as change-of-shift reports, patient care handover, transfer of accountability (TOA), handoffs, bedside reporting, or shift handover.

Nurses give a change-of-shift report orally in person, by audiotape recording, by writing information on a summary report sheet, or by standing at the patient’s bedside. Oral reports can be given in conference rooms, with staff members from both shifts participating, but this is no longer as common as it used to be. Oral reports most often take the form of one-to-one reports—for example, a report given by the night nurse to the day nurse (Figure 15-3). An advantage of oral reports is that they allow staff members to ask questions or clarify explanations. The nurses can see the patient together to perform needed assessments, evaluate progress, and discuss the interventions best suited to the patient’s needs. An audiotape report is given by the nurse who has completed care for the patient; this type of report is left for the nurse on the next shift to review. However, it is essential to schedule an opportunity for the incoming nurses to ask questions for clarification after they listen to the taped report. According to Popovich (2011, p. 59), human factors such as “stress, distraction, and communication problems” make change-of-shift reports more prone to error. Several Canadian hospitals have implemented standardized bedside safe patient handoffs using transfer of accountability (TOA) practice guidelines developed by their institution. The process provides an opportunity for the outgoing night nurse and the incoming day nurse to engage in a verbal report and to complete a patient safety checklist at the bedside