Unit 2

Question 1

What does PIPEDA stand for?

Answer 1

Personal info protection & electronic documents act

Question 2

Acuity Record

Answer 2

Based on type & # of nursing interventions required for providing 24 hrs care
Ex: 1-5 scale
1 = totally dependent for bathing
5 = can bathe independently

Question 3

What are the purposes of chart/record

Answer 3

1. Communication
2. Legal document
3. auditing
4. Education
5. research, ect

Question 4

2 Types of Records

Answer 4

1. Source-oriented

2. Problem-oriented

Question 5

Explain source-oriented records

Answer 5

• each discipline has own section
• predictable pattern
• disciplines document in own section
• Most common in acute care

Question 6

Explain Problem-oriented records

Answer 6

• based on pt’s problem
• all disciplines document in same area
• medically-based source
• single diagnosis
• Multiple problems #’ed & prioritized

Question 7

Explain narrative charting

Answer 7

longest
Writing story ~ pt
Date & Time (2 lines) *** a must
Short form & abbrev
Remarks = no white space

Question 8

SOAP

Answer 8

Subjective
Objective
Assessment
Plan

Question 9

SOAPIE(R)

Answer 9

Subjective
Objective
Assessment
Plan
Intervention
Evaluation
(Revision)

Question 10

PIE

Answer 10

Problem
Intervention
Evaluation
(Problem focused)

Question 11

Focus Charting: DAR(P)

Answer 11

Data
Action
Response
(Plan)

Question 12

Characteristics of focus charting

Answer 12

Based on pt’s concerns
Away from medical focus
Always in combination w/ other forms of documentation

Question 13

About Charting By Exception (CBE)…

Answer 13

Very common
Looks @ normal for “average human”
Only document deviations
includes observations, nsg interventions, pt response

Question 14

About Computerized systems

Answer 14

Has std care plans –> individualize for pt
efficient & effective (ex: upload x-rays)
Some legal implications

Question 15

About Case Management

Answer 15

uses critical pathways = care maps
Can use CBE
pathway for specific disease
Common in ER
Document deviations
Difficult for complex patients

Question 16

Types of forms

Answer 16

1. Admission database
2. Standardized care plan
3. Kardex
4. Flowsheets
5. Progress notes
6. Discharge summary
7. Longterm/ home care
8. Incidence reports

Question 17

Characteristics of KARDEX

Answer 17

• not permanent
• important in ICU
• Can be in pencil

Question 18

Discharge summary

Answer 18

simple terms
2 copies (1 for pt , 1 for chart)

Question 19

Guidelines of Documentation

Answer 19

Timely
logical order
meet std's
legible (blue/black ink)
accepted abbrev/ symbols
sign ALL entries
facts only
accurate
thorough & complete

Question 20

All documentation contains:

Answer 20

1. assessment data
2. nsg interventions
3. outcomes

Question 21

Of the following types of documentation, which takes the longest, but gives the most detail?
A. Narrative
B. SOAP
C. Focus charting
D. Chart by exception

Answer 21

A. Narrative

Question 22

Which of the following is the best example of quality documentation?
A. Enema administered as ordered, with patient in the left side-lying position
B. Patient seemed depressed today; not doing as well as before
C. Quarter-sized lump noted on left elbow; patient states pain is “better”
D. 6-cm incision on right lower quadrant, edges pink and well approximated with sutures; no drainage noted

Answer 22

D. 6-cm incision on right lower quadrant, edges pink and well approximated with sutures; no drainage noted

Question 23

Which of the following is a guideline for legally sound documentation?
A. Record all entries legibly and in blue ink.
B. If an order is questioned, record that clarification was sought.
C. To use time more efficiently, wait until the end of shift to record what happened throughout the shift.
D. If an error is made, use correction fluid to maintain neatness. Then record the note correctly over dried correction fluid to make optimum use of space.

Answer 23

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

Question 24

Which of the following is one purpose of the patient’s medical record?
A. Education and research
B. Ensuring accurate change-of-shift reports
C. Legal documentation and maintenance of incident reports
D. Auditing–monitoring and ease in locating procedure guidelines

Answer 24

A. Education and research

Question 25

Which of the following represents a breach of confidentiality and privacy? A. A patient is allowed to see and get copies of the patient’s medical record. B. A nurse telephones the patient’s church to have the patient’s name placed on a prayer list. C. A certified nursing assistant documents vital signs on a graphic sheet in the patient’s chart. D. A student nurse covers the patient’s identifying information while copying the patient’s medication administration record and uses the copy to look up the medications in a drug book while on the unit.

Answer 25

B. A nurse telephones the patient’s church to have the patient’s name placed on a prayer list.

Question 26

A patient is complaining of pain at 0400. The nurse telephones Dr. Rice and receives an order for oxycodone hydrochloride 5 mg one tablet every four hours as needed. It is wise for the nurse to do which one of the following? A. Repeat the prescribed order back to the physician. B. Document the following immediately on the physician’s order sheet: “0415 oxycodone hydrochloride 5 mg q4h prn. T.O. Dr. Rice.” C. Complete an incident report to assist the unit’s quality improvement program so that awakening physicians during the night can be avoided. D. Wait until the physician makes rounds in the morning and remind him to write the order to cover the nurse for the oxycodone hydrochloride the nurse gave during the night

Answer 26

A. Repeat the prescribed order back to the physician.

Question 27

As the nurse enters the patient’s room, the nurse notices that he is anxious to say something. The patient quickly exclaims, “I don’t know what’s going on; I can’t get an explanation from my doctor about the results of my test. I want something done about this.” Which of the following is the most appropriate documentation of the patient’s emotional status? A. The patient has a defiant attitude. B. The patient appears to be upset with his physician. C. The patient is demanding and complains frequently. D. The patient stated that he felt frustrated by the lack of information he has received regarding his diagnostic tests.

Answer 27

D. The patient stated that he felt frustrated by the lack of information he has received regarding his diagnostic tests.

Question 28

A manager is reviewing the nurses’ notes in a patient’s medical record. She finds the following entry: “Patient is difficult to care for, refuses suggestion for improving appetite.” Which of the following directions should the manager give to the staff nurse who entered the note? A. Avoid rushing when charting an entry. B. Use correction fluid to remove the entry. C. Draw a single line through the statement and initial it. D. Enter only objective and factual information about the patient.

Answer 28

D. Enter only objective and factual information about the patient.

Question 29

A nursing instructor is helping a student nurse with discharge planning for a patient. The instructor realizes that further education is needed when the student nurse says which of the following? A. “I need to go over the patient’s medications with him in terms he will understand.” B. “I really can’t start discharge planning until the physician writes the discharge orders.” C. “I will give the patient’s wife the appointment time I scheduled for follow-up and a list of agencies that provide medical supplies.” D. “I will review signs and symptoms of infection with the patient so he will know what to watch for and will realize he should seek medical treatment if these occur.”

Answer 29

B. “I really can’t start discharge planning until the physician writes the discharge orders.”

Question 30

``` Which of the following is a method of charting in which the nurse writes a progress note only when the standardized statement on the form is not met? A. Narrative method B. Source record C. Problem-oriented medical record D. Charting by exception ```

Answer 30

D. Charting by exception

Question 31

When a nurse follows the SOAP method of charting, the information the nurse would record under “O” would be which of the following? A. “My foot keeps throbbing.” B. Right foot is red with +4 pitting edema and capillary refill less than three seconds. C. Patient has an alteration in comfort related to swelling in right foot and keeping foot in dependent position. D. Offer “as needed” pain medication every four hours as ordered. Instruct patient on nonpharmacological pain-relieving measures. Elevate foot on pillows.

Answer 31

B. Right foot is red with +4 pitting edema and capillary refill less than three seconds.

Question 32

Accurate entries are an important characteristic of good documentation. Which of the following charting entries is most accurate in the way it is written? A. Patient up, out of bed, walked down hallway with assistance, tolerated well B. Patient up, out of bed, walked 15 metres and back down hallway, tolerated well C. Patient up, out of bed, walked 15 metres and back down hallway with assistance from nurse D. patient up, out of bed, walked 15 metres and back down hallway with assistance from nurse, heart rate 88 and regular before exercise, 94 and regular after exercise.

Answer 32

D. patient up, out of bed, walked 15 metres and back down hallway with assistance from nurse, heart rate 88 and regular before exercise, 94 and regular after exercise.

Question 33

Which of the following is one advantage of standardized care plans? A. They are used independently by the nurse. B. They establish clinically sound standards of care for similar groups of patients. C. They inhibit nurses’ identification of unique, individualized therapy for patients. D. They make quality improvement audits unnecessary.

Answer 33

B. They establish clinically sound standards of care for similar groups of patients.

Question 34

You are giving a change-of-shift report. Which of the following is the most appropriate report statement? A. “I gave Mrs. Blake a bath, combed her hair, and brushed her teeth. I changed her linens and took her vital signs. After she rested, I gave her some apple juice.” B. “I think Mrs. Frank in 120-2 needs to go home! She is constantly on her light wanting her pillow fluffed! She acts like she’s a queen and we are her servants! I heard she is pretty wealthy.” C. “You’re going to have a busy shift. Mrs. Adams will need to be transferred for her radiation treatment, Mr. Brown needs to go to radiology, the preoperative medication should be given to Mrs. Jones, and Mr. Henry’s daughter will be coming in to talk with you.” D. “David Jackson, in 121-1, a 92-year-old patient of Dr. Able, is here with pneumonia. He is receiving oxygen at two litres per nasal cannula. He has crackles in his right lower lobe, clear rest. He can get up with assistance of one. He has been coughing up thick, yellow-tinged sputum after his breathing treatments. He gets them every six hours. His next treatment will be at 0800.”

Answer 34

D. “David Jackson, in 121-1, a 92-year-old patient of Dr. Able, is here with pneumonia. He is receiving oxygen at two litres per nasal cannula. He has crackles in his right lower lobe, clear rest. He can get up with assistance of one. He has been coughing up thick, yellow-tinged sputum after his breathing treatments. He gets them every six hours. His next treatment will be at 0800.”

Question 35

``` A patient tells the nurse, “I have stomach cramps and feel nauseous.” This is an example of which type of data? A. Objective B. Historical C. Subjective D. Biographical ```

Answer 35

C. Subjective

Question 36

Patients frequently request copies of their medical records. The nurse understands that which of the following is correct? A. Only the families may read the records. B. Patients have the right to read those records. C. Patients are not allowed to read those records. D. Only health care providers have access to the records.

Answer 36

B. Patients have the right to read those records.