Alexandra Bozan
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UNIT III: Person-Centered Care and the Nursing Process Chapter 16: Documenting, Reporting, Conferring and Using Informatics

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Alexandra Bozan
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Chapter 16: Documenting, Reporting, Conferring and Using Informatics

Chapter 16: Documenting, Reporting, Conferring and Using Informatics

Question 1 of 37

1

How could the nurse researcher obtain information from a client record?

Select one of the following:

  • Study client records

  • Examine institutional procedures

  • audit discharge records

  • interview nursing staff

Explanation

Question 2 of 37

1

The student nurse is reviewing physician orders written on a client's chart. Which entry is written incorrectly because it's on the do not use list of the Joint Commission on Accreditation of Healthcare Organization?

Select one of the following:

  • Valium 5 mg po on-call to the OR

  • Epogen 6500 U SQ Daily

  • Synthroid 0.125 po daily

  • Tylenol 650 mg po every 4 hours for fever greater than 102 degrees F

Explanation

Question 3 of 37

1

The Joint Commission specifies that nursing care data related to patient assessments, nursing diagnoses, or patient needs, nursing interventions, and patient outcomes, are temporarily integrated into the patient record.

Select one of the following:

  • True
  • False

Explanation

Question 4 of 37

1

All information about patients is considered private or confidential.

Select one of the following:

  • True
  • False

Explanation

Question 5 of 37

1

Fill the blank spaces to complete the text.

Record patient findings (observations of behavior) rather than of these findings.

Explanation

Question 6 of 37

1

Fill the blank spaces to complete the text.

Document the to questionable medical orders or treatment (or failure to treat). Factually the and the physician was notified of the concern and the exact physician response. If a nurse administrator was contacted, document this.

Explanation

Question 7 of 37

1

Never document interventions before carrying them out

Select one of the following:

  • True
  • False

Explanation

Question 8 of 37

1

You can skip lines when documenting.

Select one of the following:

  • True
  • False

Explanation

Question 9 of 37

1

Draw a double line through blank spaces.

Select one of the following:

  • True
  • False

Explanation

Question 10 of 37

1

Fill the blank spaces to complete the text.

Sign your , and to each entry.

Explanation

Question 11 of 37

1

Fill the blank spaces to complete the text.

Draw a through an incorrect entry, and write the words or , above or beside the entry and sign. Then rewrite the entry correctly.

Explanation

Question 12 of 37

1

Actual patient names and other identifiers should not be used in written or oral student reports.

Select one of the following:

  • True
  • False

Explanation

Question 13 of 37

1

Fill the blank spaces to complete the text.

To release a patient's health information for purposes other than , or routine operations. the patient must be asked to sign an .

Explanation

Question 14 of 37

1

Fill the blank spaces to complete the text.

An or can help with knowing your agency's policies regarding the patient's rights to accessing record.

Explanation

Question 15 of 37

1

Fill the blank spaces to complete the text.

The only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a . The order must be given directly by the physician or nurse practitioner to a registered professional nurse or pharmacist, who , , , and the order.

Explanation

Question 16 of 37

1

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with a diagnosis of appendicitis. The physician has ordered 10 mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follows recommended guidelines?

Select one or more of the following:

  • 6/12/15 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated, M. Patrick RN

  • 6/12/15 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick RN

  • 6/12/15 0945 30 minutes following administration of morphine 10 mg IV patient reports pain as 2 on a scale of 1 to 10. M. Patrick RN

  • 6/12/15 0945 Morphine IV 10 mg will be administered to patient every 3-4 hours. M. Patrick RN

  • 6/12/15 0945 Patient reports severe pain in right lower quadrant. M. Patrick RN

  • 6/12/15 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick RN

Explanation

Question 17 of 37

1

A nurse is documenting the care given to a 56 year old patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing change was performed on the left leg. What would be the best action of the nurse to correct this documentation?

Select one of the following:

  • Erase or use correcting fluid to completely delete the error

  • Draw a single line through the entry and rewrite it above or beside it

  • Use a permanent marker to block out the mistakes entry and rewrite it

  • Remove the page w/the error and rewrite the data on that page correctly

Explanation

Question 18 of 37

1

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response?

Select one of the following:

  • I'm sorry but patients are not allowed to copy their medical records

  • I can make a copy of your record for you right now

  • You can read your record while you are still a patient, but copying records are not permitted according to HIPPA rules

  • I will need to check with our records department to get you a copy

Explanation

Question 19 of 37

1

According to HIPPA, if a health institution wants to release a patient's health information for purposes other than treatment, payment and routine health care operations, the patient must be asked to sign an authorization. The nurse is aware that there are exceptions to this requirement. In which of the following cases is an authorization form not needed?

Select one or more of the following:

  • News media are preparing a report on the condition of a public figure

  • Data are needed for the tracking and of disease outbreaks

  • protected health information is needed by a coroner

  • child abuse or neglect is suspected

  • protected health information is needed to facilitate organ donation

  • the sister of a patient with Alzheimer's wants to help provide care

Explanation

Question 20 of 37

1

A friend of a nurse calls and asks if she is still working at Memorial Hospital. The nurse replies "Yes". The friend tell the nurse that his girlfriend's father was just admitted as a patient and he wants the nurse to find out how he is. The friend states "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her" What is the best initial response the nurse should make?

Select one of the following:

  • You shouldnt be asking me to do this. I could be fined or even lose my job for disclosing this information

  • Sorry but I'm not able to give information about patients to the public, even when my best friend or a family member asks

  • Because of HIPPA, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble.

  • Why do you think Sue isn't talking about her worries?

Explanation

Question 21 of 37

1

A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication?

Select one of the following:

  • Every 3 hours

  • Every 4 hours

  • Daily

  • as needed

Explanation

Question 22 of 37

1

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the physician's order sheet. The nurse's best response is

Select one of the following:

  • Thank you for taking care of this

  • Get a second nurse to listen to the order, and after writing the order on the physician order sheet, have both nurses sign it

  • I am sorry, but verbal orders can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly.

  • Try calling another resident for the order or wait until the next shift

Explanation

Question 23 of 37

1

A nurse is looking for trends in a postopertive patient's vital signs. Which documents would the nurse consult first?

Select one of the following:

  • admission sheet

  • admission nursing assessment

  • activity flow sheet

  • graphic record

Explanation

Question 24 of 37

1

A nurse is using the SOAP format of documentation to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation?

Select one of the following:

  • a patient problem list

  • notes describing the patient's condition

  • overall trends in patient status

  • planned interventions and patient outcomes

Explanation

Question 25 of 37

1

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a male patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Label the following correctly:

: I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer

: Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump

: You want me to discontinue the PCA pump until you see him tonight at patient rounds

: I am Rosa Clark, an RN working on the second floor of South Street Hospital

: Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer

: I think the dosage of morphine in Mrs. Sanchez's PCA pump needs to be lowered

Drag and drop to complete the text.

    Situation
    Assessment
    Read-back of orders/response
    Identity/Introduction
    Background
    Recommendation

Explanation

Question 26 of 37

1

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest?

Select one of the following:

  • Narrative notes

  • PIE

  • CBE

  • FOCUS

Explanation

Question 27 of 37

1

A nurse on the night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

Select one of the following:

  • Gauging the nurse's professional performance over time

  • Following up the incident with other members of the care team

  • Protecting the nurse and the hospital from litigation

  • Identifying risks and ensuring future safety for clients

Explanation

Question 28 of 37

1

A physician suggests that a nurse use the computer terminal that is available at the point of care or at the client's bedside. What is the probable reason for the physician's suggestion?

Select one of the following:

  • the client needs to check the entry as well

  • there are limited computer modules available

  • it solves the space constraint in the hospital

  • it keeps the nurse close to the source of data

Explanation

Question 29 of 37

1

How can the nurse researcher obtain information from a client record?

Select one of the following:

  • examine institutional procedures

  • audit discharge records

  • study client records

  • interview nursing staff

Explanation

Question 30 of 37

1

A group of nurses have established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of what?

Select one of the following:

  • Telemedicine

  • EMR

  • Nursing infomatics

  • Computerized documentation

Explanation

Question 31 of 37

1

When maintaining medical records for a client, the nurse knows that a medical record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?

Select one of the following:

  • use abbreviations wherever possible

  • record all facts and subjective interpretations

  • leave spaces between entries and signatures

  • ensure that the client's name appears on all pages

Explanation

Question 32 of 37

1

A healthcare facility plans to evaluate and revise the plan of care for a client based on the client's medical records. The physician, dietician, and the nurse involved in the client's care are required to collate all of the information for easy access. Which style do you think the agency is following in order to record the client details?

Select one of the following:

  • Narrative

  • SOAP

  • FOCUS

  • PIE

Explanation

Question 33 of 37

1

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note, in a short-hand method using well-defined standards practice. Which of the following best defines this type of charting?

Select one of the following:

  • CBE

  • FOCUS

  • PIE

  • Variance charting

Explanation

Question 34 of 37

1

Which of the following information about the patient would a nurse include as part of a minimum data set when using electronic medical records?

Select one or more of the following:

  • insurance

  • sex/gender

  • admission date

  • health history

  • physical assessment

Explanation

Question 35 of 37

1

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?

Select one of the following:

  • To transmit health records between insurance companies

  • to investigate the quality of care in the agency

  • to release the entire health records for research

  • to inform family and others concerned about the client's care

Explanation

Question 36 of 37

1

The nurse should utilize ISBARR communication during which of the following clinical situations?

Select one of the following:

  • When reporting to a client's family member or significant other

  • When providing a change of shift report to a colleague

  • When communicating a client's change in condition to the physician

  • When documenting the care that was provided to a client whose condition recently deteriorated

Explanation

Question 37 of 37

1

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?

Select one of the following:

  • FOCUS

  • narrative

  • SOAP

  • PIE

Explanation

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