Documentation (chapter 4) Flashcards
The patient is a 24-year-old man who is diagnosed with possible HIV infection while being treated for active pneumonia. He has stated that the nurse may share test result information with his significant other but nothing else at this time. With whom may the nurse communicate regarding this information?
a. The patient’s parents
b. The patient’s significant other only
c. No one in the hospital until the patient says so
d. The patient’s physician, significant other, and laboratory personnel
ANS: D
All members of the health care team are legally and ethically obligated to keep patient information confidential. Do not discuss the patient’s examinations, observations, conversations, or treatments with other patients or staff not involved in the patient’s care, unless permission is granted by the patient.
Which of the following is the best example of objective charting?
a. “The patient states that he has been having severe chest discomfort.”
b. “The patient is lying in bed and seems to be in considerable pain.”
c. “The patient appears to be pale and diaphoretic and complains of nausea.”
d. “The patient’s skin is ashen and respiratory rate is 32 and labored.”
ANS: D
A record or report contains descriptive, objective information about what you see, hear, feel, and smell. An objective description is the result of direct observation and measurement, such as “respiratory rate 20 and unlabored.” Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. The only subjective data included in a record are what the patient actually verbalizes. Write subjective information with quotation marks, using the patient’s exact words whenever possible. For example, you record, “Patient states, ‘my stomach hurts.’” Avoid terms such as appears, seems, and apparently, which are often subject to interpretation. For example, the description “the patient seems to be in pain” does not accurately communicate the facts to another caregiver. The phrase seems is not supported by any objective facts.
Which of the following is the best example of accurate documentation?
a. “Abdominal wound is 5 cm in length without redness, edema, or drainage.”
b. “OD to be irrigated qd with NS.”
c. “No complaint of abdominal pain this shift.”
d. “Patient watching TV entire shift.”
ANS: A
The use of exact measurements in documentation establishes accuracy. For example, charting that an abdominal wound is “5 cm in length without redness, edema, or drainage” is more descriptive than “large wound healing well.” It is essential to know the institution’s abbreviation list, and to use only accepted abbreviations, symbols, and measures (e.g., metric), so that all documentation is accurate and is in compliance with standards. For example, the abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word “daily” or “every day” on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). The term “no complaint” may indicate stoicism on the part of the patient. He may have been in excruciating pain but never complained of it. It also creates a question related to the assessment skills of the nurse. It is essential to avoid unnecessary words and irrelevant details. For example, the fact that the patient is watching TV is only necessary to report when this activity is significant to the patient’s status and plan of care.
Patients on the unit have their vital signs taken routinely at 0800, 1200, 1600, and 2000. At 1000, a patient complains of feeling “light-headed.” The nurse takes the patient’s vital signs and finds blood pressure to be lower than usual. Within 15 minutes, the patient says that he feels better. The nurse rechecks the blood pressure and finds that it is now back to normal. How should the nurse handle documentation for this episode?
a. Document the 1000 vital signs in the graphic record only.
b. Not report the incident because it was a transient episode.
c. Document the vital signs in the graphic and progress record.
d. Document the vital signs as 12 o’clock signs.
ANS: C
When documenting a significant change on a flow sheet, you describe the change, including the patient response to nursing interventions, in the progress notes. For example, if a patient’s blood pressure becomes dangerously low, record the blood pressure in the progress notes, as well as relevant assessment such as pallor and dizziness and any interventions performed to raise the blood pressure. Common issues in malpractice caused by inadequate or incorrect documentation include failing to give a report or giving an incomplete report to an oncoming shift and failing to document the correct time of events.
The nurse manager is attempting to determine the staffing needs of the unit. One tool that she may use to determine the level of care needed would be:
a. the standardized care plan.
b. the acuity record.
c. the patient care summary.
d. flow sheets.
ANS: B
Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. An acuity recording system determines the hours of nursing care and the number of staff required for a nursing unit. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration.
A preprinted guideline used to care for patients with similar health problems is known as the:
a. acuity record.
b. standardized care plan.
c. patient care summary.
d. flow sheet.
ANS: B
Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines that are used in caring for patients with similar health problems. Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration.
The patient is ready to go home from the hospital. What does the nurse provide to the patient and his family before he leaves the facility?
a. Discharge summary
b. Standardized care plan
c. Patient care summary
d. Flow sheet
ANS: A
When a patient is discharged from a health care institution, the members of the health care team prepare a discharge summary. A discharge summary provides important information related to the patient’s ongoing health problems and need for health care after discharge. You enhance discharge planning when you are responsive to changes in patient condition and involve the patient and family in the planning process. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration.
Which is a delivery model that coordinates and links health care services to patients and families?
a. Critical pathways
b. Charting by exception
c. SOAP
d. Case management
ANS: D
Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. Critical pathways state the goals and important elements of care based on best practice and patient expectations by documenting, monitoring, and evaluating variances and providing resources and outcomes. This system involves completing a flow sheet that incorporates those standard assessment and intervention criteria by placing a check mark in the appropriate standard box on the flow sheet to indicate normal findings and routine interventions. The logic for SOAP (IE) notes is similar to that for the nursing process: Collect data about the patient’s problems, draw conclusions, and develop a plan of care.
The patient has been in the hospital for a hip replacement. According to his critical pathway, he should have his Foley catheter discontinued on the fourth day after surgery. Instead, the patient has it removed on the third day and is voiding normally with no problems. This would be a sign of:
a. a negative variance.
b. positive case management.
c. a positive variance.
d. use of SBAR.
ANS: C
Variances are unexpected occurrences, unmet goals, and interventions not specified within the critical pathway time frame that reflect a positive or negative change. A positive variance occurs when a patient progresses more rapidly than is anticipated in the case management plan (e.g., use of a Foley catheter is discontinued a day early). A negative variance occurs when activities on the critical pathway do not happen as predicted, or outcomes are unmet (e.g., oxygen therapy is necessary for a new-onset breathing problem). Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. SBAR is a technique that provides a framework for communication between members of the health care team about a patient’s condition. SBAR is a concrete mechanism used for framing conversations, especially critical ones, requiring a nurse’s immediate attention and action.
Which is a primary difference between home care and hospital care?
a. Documentation systems need to provide information for the home health nurse only.
b. Documentation no longer affects reimbursement.
c. Services are assumed and need less documentation.
d. The patient and the family witness most of the care provided.
ANS: D
One primary difference is that the patient and the family rather than the nurse witness most of the care provided. Documentation systems need to provide the entire health care team with the necessary information to work together effectively, supply quality control, and justify reimbursement from Medicare, Medicaid, or private insurance companies.
The patient has been transferred to the nursing home from the acute care hospital. A report was called from the hospital and was received by the RN in charge of the nursing home unit. Upon arrival, which approach is used to assess the patient?
a. The Long-Term Care Facility Resident Assessment Instrument
b. The case management model
c. Collaborative pathways
d. The charting by exception model
ANS: A
Each resident in long-term care is assessed using the Long-Term Care Facility Resident Assessment Instrument as mandated by the Omnibus Budget Reconciliation Act of 1989 (OBRA) and updated in 1998. Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. The collaborative pathways are multidisciplinary care plans that include key interventions provided and expected outcomes within an established time frame. The charting by exception model involves completing a flow sheet that incorporates those standard assessment and intervention criteria by placing a check mark in the appropriate standard box on the flow sheet to indicate normal findings and routine interventions.
The nursing assistant tells the RN that when the patient’s vital signs were taken, the patient complained that she was in a lot of pain. The nursing assistant then tells the nurse that she charted the patient’s complaint when she charted the vital signs. What instruction does the nurse need to provide to the nursing assistant?
a. The nursing assistant needs to make sure she uses the SBAR format when entering notes.
b. Nursing assistants are not allowed to chart vital signs.
c. Only the nurse can write in the progress notes.
d. The nursing assistant needs to write using blue ink to distinguish from the RN note.
ANS: C
The task of writing a progress note may not be delegated to nursing assistive personnel (NAP). The nurse instructs the NAP about what repetitive care activities should be documented on flow sheets, including vital signs, intake and output (I&O), and routine care related to ADLs.
The patient was in bed with all side rails up. During the night, the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails. After meeting the patient’s needs and assessing that the patient was not harmed, what step should the nurse take (if any)?
a. Complete an incident report and put it in the medical record.
b. Chart what happened and state that an incident report has been filled out.
c. Do nothing because the patient was not harmed.
d. Document what happened in the patient record without mentioning the incident report.
ANS: D
Document in the patient’s record an objective description of what you observed and follow-up actions taken without reference to the incident report. Incident reports are not a part of the permanent medical record but are an important source of risk management data for identifying and addressing the causes of errors made in health care organizations. You complete the report even if an injury does not occur or is not apparent.
Nursing documentation: (Select all that apply.)
a. ensures continuity of care.
b. provides legal evidence.
c. evaluates patient outcomes.
d. increases the risk of litigation.
ANS: A, B, C
Nursing documentation ensures continuity of care, provides legal evidence, and evaluates patient outcomes. Effective documentation ensures continuity of care, maintains standards, and reduces errors.
What is the goal of information management? (Select all that apply.)
a. Support decision making.
b. Improve patient outcomes.
c. Ensure patient safety.
d. Improve health care documentation.
ANS: A, B, C, D
The goal of information management is to support decision making and improve patient outcomes, improve health care documentation, ensure patient safety, and improve performance in patient care, treatment and services, governance, management, and support processes.
