CH 16 DOCUMENTING & INFORMATICS Flashcards
(36 cards)
1. A client’s diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client’s chart should be written as … A) Avelox (moxifloxacin) 400 mg daily B) Avelox (moxifloxacin) 400 mg Q.D. C) Avelox (moxifloxacin) 400 mg qd D) Avelox (moxifloxacin) 400 mg OD
Ans:
A
Feedback:
Among the JCAHO’s list of “do not use” abbreviations are Q.D., qd, and OD when denoting a once-per-day drug administration. Because of the potential for misinterpretation and consequent drug errors, the JCAHO recommends writing “daily” in the order.
2.
The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks?
A)
Vulnerability to legal liability since nurse’s safe, routine care is not recorded
B)
Increased workload for nurses in order to complete necessary documentation
C)
Failure to identify and record client problems and associated interventions
D)
Significant differences in the charting between nurses due to lack of standardization
Ans:
A
Feedback:
A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework.
3. The nurse managers of a home health care office wish to maximize nurses’ freedom to characterize and record client conditions and situations in the nurses’ own terms. Which of the following documentation formats is most likely to promote this goal? A) Narrative notes B) SOAP notes C) Focus charting D) Charting by exception
Ans:
A
Feedback:
One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.
4.
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse’s following statements would appear at the beginning of a charting entry?
A)
“Client complaining of abdominal pain rated at 8/10.”
B)
“Client is guarding her abdomen and occasionally moaning.”
C)
“Client has a history of recent abdominal pain.”
D)
“2 mg Dilaudid PO administered with good effect”
Ans:
A
Feedback:
The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a complaint of pain. The nurse’s objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.
5. What is the nurse’s best defense if a client alleges nursing negligence? A) Testimony of other nurses B) Testimony of expert witnesses C) Client’s record D) Client’s family
Ans:
C
Feedback:
The client record is the only permanent legal document that details the nurse’s interactions with the client. It is the best defense if a client or client surrogate alleges nursing negligence.
6.
A nurse is documenting the intensity of a client’s pain. What would be the most accurate entry?
A)
“Client complaining of severe pain.”
B)
“Client appears to be in a lot of pain and is crying.”
C)
“Client states has pain; walking in hall with ease.”
D)
“Client states pain is a 9 on a scale of 1 to 10.”
Ans:
D
Feedback:
Information should be documented in a complete, accurate, relevant, and factual manner. Avoid interpretations of behavior, generalizations, and words such as “good.”
7.
Which of the following data entries follows the recommended guidelines for documenting data?
A)
“Client is overwhelmed by the diagnosis of pancreatic cancer.”
B)
“Client’s kidneys are producing sufficient amount of measured urine.”
C)
“Following oxygen administration, vital signs returned to baseline.”
D)
“Client complained about the quality of the nursing care provided on previous shift.”
Ans:
C
Feedback:
The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as “good,” “average,” “normal,” or “sufficient,” which may mean different things to different readers. The nurse should also avoid generalizations such as “seems comfortable today.” The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner.
8. Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry? A) Alice J, RN B) A. Jones, RN C) Alice Jones D) AJRN
Ans:
B
Feedback:
Each entry is signed with the first initial, last name, and title. In this case, A. Jones, RN, is correct.
9.
A student has reviewed a client’s chart before beginning assigned care. Which of the following actions violates client confidentiality?
A)
Writing the client’s name on the student care plan
B)
Providing the instructor with plans for care
C)
Discussing the medications with a unit nurse
D)
Providing information to the physician about laboratory data
Ans:
A
Feedback:
Students using client records are bound professionally and ethically to keep in strict confidence all the information they learn from those records. The student may discuss care with the instructor, medications with a staff nurse, and laboratory data with the physician. The student should not use actual client names or other identifiers in written assignments or oral reports.
10. A physician’s order reads “up ad lib.” What does this mean in terms of client activity? A) May walk twice a day B) May be up as desired C) May only go to the bathroom D) Must remain on bed rest
Ans:
B
Feedback:
The abbreviation “up ad lib” means the client may be up as desired.
11. In what type of documentation method would a nurse document narrative notes in a nursing section? A) Problem-oriented medical record B) Source-oriented record C) PIE charting system D) Focus charting
Ans:
B
Feedback:
A source-oriented record is one in which each health care group keeps data on its own separate form (e.g., physicians, nurses, and laboratory). Progress notes written by nurses using this method are narrative notes.
12. Which one of the following methods of documentation is organized around client diagnoses rather than around patient information? A) Problem-oriented medical record (POMR) B) Source-oriented record C) PIE charting system D) focus charting
Ans:
A
Feedback:
The POMR is organized around a client’s problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care.
13. A nurse organizes client data using the SOAP format. Which of the following would be recorded under “S” of this acronym? A) Client complaints of pain B) Client history C) Client’s chief complaint D) Client interventions
Ans:
A
Feedback:
The SOAP format (subjective data, objective data, Assessment [the caregiver’s judgment about the situation], plan) is used to organize data entries in the progress notes of the POMR. A client complaint of pain is subjective data (S).
14. Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse? A) Problem-oriented medical record B) Charting by exception C) PIE charting system D) Focus charting
Ans:
B
Feedback:
Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or “exceptions” to these standards are documented in narrative notes. A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing.
15.
A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next?
A)
Date it and put it in the client’s record.
B)
Sign it and put it in the Kardex.
C)
Individualize it to the specific client.
D)
Use it as printed, based on common needs.
Ans:
C
Feedback:
Standardized care plans that identify common problems and needs with relation to select client cohorts may be used. Unless such care plans are individualized to a specific client, however, they may not address individual client needs.
16. What part of the client’s record is commonly used to document specific client variables, such as vital signs? A) Progress notes B) Nursing notes C) Critical paths D) Graphic record
Ans:
D
Feedback:
The graphic record is a form used to document specific client variables such as vital signs, weight, intake and output, and bowel movements.
17. A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)? A) PIE system B) Minimum data set C) OASIS D) Charting by exception
Ans:
B
Feedback:
Long-term care documentation is specified by the RAI with the minimum data set forming the foundation for the assessment. This is required in all facilities certified to participate in Medicare or Medicaid. OASIS is used in the home health care industry.
18. What is the primary purpose of an incident report? A) Means of identifying risks B) Basis for staff evaluation C) Basis for disciplinary action D) Format for audiotaped report
Ans:
A
Feedback:
An incident report, also termed a variance or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a client, employee, or visitor. Incident reports should not be used for disciplinary action against staff members.
19. A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called? A) Nursing care conferences B) Staff visits C) Interdisciplinary referrals D) Nursing care rounds
Ans:
D
Feedback:
Nursing care rounds are procedures in which a group of nurses visits select clients individually at each client’s bedside. The primary purposes are to gather information to help plan and evaluate nursing care and to provide the client with an opportunity to discuss care.
20. A nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to nursing? A) Data, information, knowledge B) Process, documentation, analysis C) Research, controls, variables D) Hypothesis, nursing, practice
Ans:
A
Feedback:
According to the ANA Scope and Standards of Nursing Informatics Practice, nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support clients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology (ANA, 2001, p. vii).
21.
A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse?
A)
“I am sorry that you had to suffer this way. The nurse on night duty should be fired.”
B)
“It’s hard to be in bed and ask for help. You ring for a nurse who never seems to help.”
C)
“You seem to be impatient. The nurses work very hard and they do whatever they can.”
D)
“I can see that you are angry. What the nurse did is wrong, and it won’t happen again.”
Ans:
B
Feedback:
The nurse should empathize with the client to perceive how the client is feeling. The nurse shares his or her perception with the client, which makes him comfortable to share his anxieties, fear, and concerns. The first response conveys pity on the client, which is inappropriate. In the third response, the nurse is taking the side of the nursing staff and the client may not like it. The fourth response is nontherapeutic.
22.
A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports?
A)
Pay courtesy calls to staff members before attending the meeting.
B)
Wait for the physicians to arrive before exchanging notes.
C)
Avoid asking questions related to the medical record.
D)
Come prepared with material required to take notes.
Ans:
D
Feedback:
The nurse should come prepared with material required to take notes during the change-of-shift reports. The nurse should not delay the meeting for change-of-shift report by paying courtesy calls to staff members before attending the meeting. Change-of-shift reports are not conducted in the presence of physicians, thus the nurse does not need to wait for the physicians to arrive before exchanging notes. The nurse should ask questions related to the medical record if any information is unclear.
23.
A nurse is manually documenting information related to a client’s condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation?
A)
Erase the incorrect statement and write the correct one.
B)
Cross out the wrong statement in a way that is not readable.
C)
Use correction fluid to obliterate what has been written.
D)
Cross out the incorrect statement with a single line.
Ans:
D
Feedback:
When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one, nor cross out the wrong statement in a way that makes the statement unreadable, nor use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.
24.
A nurse caring for a client who is being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation?
A)
Information is documented in separate forms by each health care personnel.
B)
It is a unified, cooperative approach for resolving the client’s problems.
C)
It is organized at one location according to the client’s health problems.
D)
It is compiled to facilitate communication among health care professionals.
Ans:
A
Feedback:
Source-oriented documentation is a record organized according to the source of documented information. This type of record contains separate forms on which health care personnel make written entries about their own specific activities in relation to the client’s care. The problem-oriented method of recording demonstrates a unified, cooperative approach to resolving the client’s problems. Source-oriented records are organized at numerous locations; there is not one location for information. The problem-oriented record is compiled to facilitate communication among health care professionals.
