Documenting and Reporting Chapter 16

Question 1

Identify the purposes of the client health record.

Answer 1

Answer:
The purposes of the client record are as follows:
● Communication among health professionals and continuity of care
● Legal documentation
● Education of health professionals
● Legislative requirements
● Quality improvement
● To meet professional standards of care
● Identification of the cost of care for reimbursement and utilization review
● Health-related research

Question 2

What are the key differences in the organization of source-oriented records, problem-oriented records, electronic documentation systems, and CBE systems?

Answer 2

Answer:
The source-oriented record is organized according to discipline. Each discipline charts in its defined section of the chart. The problem-oriented record is organized around a patient problem list. All disciplines chart on shared notes that are referenced to the identified problem. The EHR can contain both source-oriented and problem-oriented records. In a CBE system only significant findings or exceptions to standards and norms of care are charted. CBE uses preprinted flowsheets to document most aspects of care, and it assumes that unless a separate entry has been made (an exception), all standards have been met, prescribed care has been done, and the patient has responded normally. Normal responses for various assessments are defined on the form.

Question 3

What are three advantages of traditional, paper health records?

Answer 3

Answer:
● Familiar documentation model with long history of use in healthcare
● Does not require large databases and secure networks to function
● No need for downtime processes
● Relatively inexpensive to create new forms and update old ones

Question 4

What are three advantages of electronic health records?

Answer 4

Answer:
● Multiple healthcare providers access the same information at same time
● Up to one-quarter reduction in time nurses spend documenting client data
● Information stored and retrieved quickly and easily
● Information accessed remotely to improve care
● Specific protocols programmed into the system based on the condition and problems of the client
● Embedded protocols improve consistency of care and adherence to clinical practice guidelines.
● Medical errors prevented through programmed alerts and clinical reminders that automatically display cautions and warnings when actions are taken that could be harmful
● Repetition and duplication reduced
● Communication improved between healthcare providers
● Queries run and data collected in reports that gather specific information regarding nursing care or client characteristics very quickly
● Information permanently stored and not likely to be lost
● Confidentiality of client information protected by tracking everyone who enters the chart, proper security clearances, unique passwords, and restricted access
● A few EHRs integrate client information between multiple areas of the organization so that one area can see information from another area as it is verified
● Helps organizations more effectively meet regulatory requirements and accreditation goals

Question 5

Narrative format nursing documentation

Answer 5

tells the story of the patient’s experience in a chronological format. Patient status, activities, and response to treatment may all be included in narrative charting.

Question 6

PIE format nursing documentation

Answer 6

is organized according to problem, interventions, and evaluation. Problems are identified at the admission assessment. Subsequent entries begin with identification of the problem number. This type of charting establishes an ongoing care plan.

Question 7

SOAP charting nursing documentation

Answer 7

is organized according to subjective data, objective data, assessment, and plan. This format may be used to address single problems or to write summative patient notes.

Question 8

Focus® charting nursing documentation

Answer 8

is not necessarily organized according to problems. It can highlight the client’s concerns, problems, or strengths. Charting occurs in three columns. The first column contains the time and date. The second column identifies the focus or problem addressed in the note. The third column contains charting in a DAR format. DAR is an acronym for data, action, and response.

Question 9

CBE charting nursing documentation

Answer 9

utilizes preprinted flowsheets to document most aspects of care. CBE assumes that unless a separate entry is made—an exception—all standards have been met with a normal response. CBE flowsheets vary by specialty and in some cases even by diagnosis.

Question 10

FACT system nursing documentation

Answer 10

is similar to CBE in that it includes only exceptions to the norm. It includes four key elements: (1) Flow sheets individualized to specific services, (2) Assessment features standardized with baseline parameters, (3) Concise, integrated progress notes and flowsheets documenting the client’s condition and responses, and (4) Timely entries documented when care is given.

Question 11

Electronic entry format nursing documentation

Answer 11

Electronic entry format includes forms, flowsheets, and progress notes and may use a combination of electronic and paper entry. Narrative, SOAP, PIE, POC, Focus®, or FACT formats may be used in the progress notes.

Question 12

Identify at least five types of paper documentation forms.

Answer 12

Answer:
There are many types of documentation forms. Among them are nursing admission data forms, discharge summaries, flowsheets, graphic records, checklists, intake and output records, medication administration records, Kardexes or patient care summaries, integrated plans of care (IPOCs), and occurrence reports.

Occurrence forms and the Kardexâ are not part of the patient record and as such are not charting forms. They are used to document unusual events (occurrence forms) or to summarize care (Kardexâ).

Question 13

What should you document after administering a PRN medication?

Answer 13

Answer:
After administering a PRN medication, document the time and date the medication was given and the location of administration if the medication was injected on the medication administration record (MAR). In the nurses’ notes, state the reason for administering the medicine, the amount given, and the patient’s response to the medication.

Question 14

What are some reasons for the slow adoption of electronic documentation and EMRs in the United States?

Answer 14

Answer:
High cost of purchasing, customizing, and maintaining the systems; getting the existing computer applications (e.g., billing) to exchange data with the new applications (e.g., care documentation); resistance from physicians and nurses who are comfortable with paper records and see no reason to change.

Question 15

What is the purpose of an occurrence report?

Answer 15

Answer:
An occurrence report is a formal record of an unusual occurrence or accident. This is an agency report and is not part of the patient’s chart. An occurrence report is filed in many circumstances. Examples of reportable events include falls or other patient injury, loss of patient belongings, or administration of the wrong medicine. Occurrence forms are used to track problems and identify areas for quality improvement.

Question 16

What should you never ever document in a patients chart if you had to file an occurrence report?

Answer 16

Never document in a patients chart that you “filed an occurrence report”. This makes it transition from an internal report to a document that can be used in court and is legally the patients. Just document what happened into the patients chart without stating that you filed a report.

Question 17

abd

Answer 17

abdomen or abdominal

Question 18

BRP

Answer 18

bathroom privileges

Question 19

DM

Answer 19

diabetes mellitus

Question 20

fx

Answer 20

fracture

Question 21

NKDA

Answer 21

no known drug allergies

Question 22

OOB

Answer 22

out of bed

Question 23

pc

Answer 23

after meals

Question 24

PRN

Answer 24

as needed

Question 25

STD

Answer 25

sexually transmitted disease

Question 26

tid

Answer 26

three times per day

Question 27

q

Answer 27

every (note that the abbreviations Q.O.D., QOD, q.o.d., qod, Q.D., QD, q.d., and qd are on the Joint Commission “do not use” list. The letter “q” in other combinations is not on that list.

Question 28

LUQ

Answer 28

left upper quadrant

Question 29

How do home care and long-term care documentation differ from hospital-based documentation?

Answer 29

● Home care documentation must include (a) certification of homebound status, (b) ongoing assessment of the need for skilled care, (c) use of the OASIS data set, and (d) a monthly summary describing the patient’s status and ongoing needs. The patient’s physician signs this form, and this is submitted for reimbursement.

● Long-term care documentation must include (a) a comprehensive assessment using the Minimum Data Set for Resident Assessment and Care Screening (MDS) within 4 days of admission and updates every 3 months with any significant change in client condition, (b) a report of any changes in a client’s condition to the primary care provider and the client’s family, and (c) a summary by an LVN/LPN or RN either weekly for clients receiving skilled services or every 2 weeks for clients receiving intermediate care services.

Question 30

What data should be included in a handoff report?

Answer 30

Answer:
The following data are key points to include in a change-of-shift report:
● Patient’s name, age, and room number
● Patient’s admitting diagnosis (one or several may exist)
● Patient’s relevant past medical history
● Treatments the patient has received at this admission (e.g., surgery, line placements, breathing treatments)
● Upcoming diagnostics, surgeries, or treatments
● Restrictions on the patient (e.g., diet, bedrest, isolation)
● Plan of care for the patient (e.g., IV therapy, pain management, medications, wound care, patient or family concerns)
● Significant assessment findings from the previous shifts

Question 31

What are the types of handoff reports?

Answer 31

Answer:
The handoff report may be written or oral. Oral report allows interaction. Oral report may be given at the bedside or in a conference room and may be audio recorded.

Question 32

What important factors should you document when receiving a telephone prescription?

Answer 32

Answer:
The following are guidelines for telephone orders:
● Only write the prescription if you heard it yourself; no third-party involvement is acceptable.
● Repeat the prescription even if you believe you have understood it entirely. Spell unfamiliar names using a system like “B as in boy.” Pronounce digits of numbers separately; for example, instead of “seventeen” say “one, seven.”
● Make sure the verbal orders make sense with the patient’s status.
● If possible, have a second nurse listen to the prescription to verify accuracy.
● Directly transcribe the prescription onto the chart. Transcribing it onto a piece of paper and then copying it again introduces another chance of error.
● When writing the prescription, first document the date and time. Then write the text of the prescription. Following the text of the order, document “T.O.” followed by the ordering provider’s name before yours.
● Be sure you have the phone number of the provider to allow access if future questions arise.
● The physician must countersign all verbal and phone orders within 24 hours.

Question 33

What is the purpose of a verbal order? When should it be used?

Answer 33

Answer:
Verbal orders are spoken prescriptions given to you in person. Often these occur in an emergency situation. Never use verbal orders as a routine method of communicating prescriptions. Follow the same guidelines as you would use for telephone orders.

Question 34

What aspects of care should be documented?

Answer 34

Answer:
The following aspects of care should be documented:
●   Routine care
●   Assessment data
●   Any significant events or changes in condition
●   If informed consent is obtained
●   Any occurrences
●   Calls to the primary care provider
●   Teaching performed
●   Use of restraints
●   Refusal of medicines or treatments
●   Patient’s spiritual concerns

Question 35

When should care be documented?

Answer 35

Answer:

Documentation should be performed as soon as possible after you make an observation or provide care.

Question 36

How is documentation on paper different than documentation in an EHR or on an electronic digital form?

Answer 36

Answer:
Although the same principles apply, there are some differences. When you document electronically, the information is immediately available to other care providers in other settings. You do not have to wait for another provider to finish with the chart, so you can chart almost immediately after patient contact. Usually, you will not type in a narrative note but will enter a phrase or click to bring up a screen. After that, you check or indicate certain words or fields that then bring up other screens and other choices. You will struggle less with phrasing and terminology because the computer provides lists from which you choose those applicable to your patient and your interventions.

Question 37

Can charting be delegated?

Answer 37

Answer:
Each member of the team is responsible for documenting her part in the care of the patient. Nursing assistants often chart activities of daily living (ADLs), activity level, and intake and output on graphic records. You are responsible for documenting the care you provide. Never chart the actions of others as if you performed them. If an action is crucial to a chain of events, you may document that action if you observed it.

Question 38

You are a student nurse on a medical–surgical unit. You review your patient’s chart and notice that the physician has entered prescriptions that do not appear to be appropriate for your patient. The physician is still in the area. How would you handle this situation?

Answer 38

Answer:
As a student nurse, you may wish to discuss the situation with your clinical instructor or the staff nurse assigned to the patient. The physician who wrote the orders must be contacted directly to question the orders. Explain your concerns objectively. If the order still stands, you may refuse to carry out the order, but you will need to go through the chain of command on the unit to do so.

Question 39

Charting by exception:
A. is a reliable form of documentation, minimizing errors.
B. should be used only in ambulatory clinics and long-term care facilities.
C. increases the risk of liability in malpractice cases because “not documented, not done.”
D. can be used to document care accurately on stable patients.

Answer 39

Answer:
D. can be used to document care accurately on stable patients.

Rationale:
Charting by exception simplifies nursing documentation by eliminating the need to document routine, stable patient information. It should be used in conjunction with flowsheets and brief narrative charting to ensure comprehensive documentation. This form of documentation does not minimize risks because nurses need to be sure they have included both routine and variant findings. It can be used successfully in any type of healthcare setting. Liability does not increase if the nurse follows reasonable and prudent guidelines for documenting patient care information.

Question 40

When reviewing your documentation of a patient, it should reflect:
A. everything that could have been done during your shift.
B. objective, comprehensive, accurate account of patient data, nursing care provided, and patient response.
C. all the procedures, medications, and tasks that were done that day.
D. a detailed narrative account of what occurred moment by moment that shift.

Answer 40

Answer:
B. objective, comprehensive, accurate accounting of patient data, nursing care provided, and patient response.

Rationale:
Your documentation should be objective, accurate, and comprehensive, focusing on patient assessment data, interventions provided, and evaluation of the patient’s response to care or teaching. Response A is incorrect, as you should document care that was provided. Response C only includes interventions and tasks and no assessment or evaluation data. Response D may include unnecessary data. Just document your nursing actions (assessment, diagnosing, planning, interventions, and evaluation).

Question 41

Documentation of nursing care for home health patients requires which of the following? Choose all that are correct.
A. Certification of homebound status
B. Use of the OASIS data set
C. A weekly summary describing the patient’s status and ongoing needs
D. Ongoing assessment of need for skilled nursing care

Answer 41

Answer:
A, B, D. You must document evidence of homebound status, use the OASIS data set, and document ongoing need for skilled nursing care.

Rationale:
The requirement is for a monthly, not weekly, summary describing the patient’s status and ongoing needs.

Question 42

The use of abbreviations is a common practice in healthcare. The use of abbreviations provides for which of the following?
A. Decreased efficiency in documentation
B. Increased risk for medical errors
C. Uniform use in all facilities
D. Ease in understanding physician orders

Answer 42

Answer:
B. increased risk for medical errors

Answer:
The JCAHO 2008 National Patient Safety Goals identify the use of abbreviations as a significant risk factor in medical errors and is requiring that the following abbreviations not be used—u, iu, qd, and qod—because these abbreviations have been frequently cited in transcription errors.

Question 43

Identify five components of nursing documentation that demonstrate quality care that is legally defensible.

Answer 43

Answer:
Any five of the following components are an acceptable answer:
● Legibility
● Patient’s name, information, and date are on each sheet
● No blank spaces between entries
● Accurate and objective
● Errors lined out and initialed
● No Wite-Out or blacking out the error
● Signature of the care provider and his or her title
● Late entries clearly noted

Question 44

Information received on the status of a group of individual patients

Answer 44

Change-of-shift report

Question 45

Initiated at time of admission and completed at discharge

Answer 45

Discharge summary

Question 46

Documents routine, one-time, and PRN medications

Answer 46

Medication administration record

Question 47

Progress note that reflects only one health focus

Answer 47

SOAP/PIE

Question 48

Assessment data, interventions, and patient responses written in a detailed chronological manner

Answer 48

Narrative charting

Question 49

ist the important factors to document when taking a physician’s verbal order:

Answer 49

Answer:
For verbal orders, the following factors are important to document:
● Only write the prescription if you heard it yourself; no third-party involvement is acceptable.
● Repeat the prescription even if you believe you have understood it entirely. Spell unfamiliar names using a system like “B as in boy.” Pronounce digits of numbers separately; for example, instead of “seventeen” say “one, seven.”
● Make sure the verbal orders make sense with the patient’s status.
● If possible, have a second nurse listen to the order to verify accuracy.
● Directly transcribe the prescription the possibility of error.
● When writing the prescription, first document the date and time. Then write the text of the prescription. Following the text of the order, document “T.O.” followed by the ordering provider’s name before yours.
● Be sure you have the phone number of the provider to allow access if future questions arise.
● The physician must countersign all verbal and phone orders within 24 hours.

Question 50

Which of the following incidents requires the nurse to complete an occurrence report?

1) Medication given 30 minutes after scheduled dose time
2) Patient’s dentures lost after transfer
3) Worn electrical cord discovered on an IV infusion pump
4) Prescription without the route of administration

Answer 50

Answer:
2) Patient’s dentures lost after transfer

Rationale:
You would need to complete an occurrence report if you suspect your patient’s personal items to be lost or stolen. A medication can be administered within a half-hour of the administration time without an error in administration; therefore, an occurrence report is not necessary. The worn electrical cord should be taken out of use and reported to the biomedical department. The nurse should seek clarification if the provider’s order is missing information; an occurrence report is not necessary.

Question 51

The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting:

1) Separates the health record according to discipline
2) Organizes documentation around the patient’s problems
3) Highlights the patient’s concerns, problems, and strengths
4) Is designed to streamline documentation

Answer 51

Answer:
1) Separates the health record according to discipline

Rationale:
In source-oriented charting, each discipline documents findings in a separately labeled section of the chart. Problem-oriented charting organizes notes around the patient’s problems. Focus® charting highlights the patient’s concerns, problems, and strengths. Charting by exception is a unique charting system designed to streamline documentation.

Question 52

When the nurse completes the patient’s admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding?

1) NA
2) NDA
3) NKA
4) NPO

Answer 52

Answer:
3) NKA

Rationale:
The nurse can use the medical abbreviation NKA, which means no known allergies, to document this finding. NA is an abbreviation for not applicable. NDA is an abbreviation for no known drug allergies. NPO is an abbreviation that means nothing by mouth.

Question 53

The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets:

1) Are comprehensive charting forms that integrate assessments and nursing actions
2) Contain only graphic information, such as I&O, vital signs, and medication administration
3) Are used to record routine aspects of care; they do not contain assessment data
4) Contain vital data collected upon admission, which can be compared with newly collected data

Answer 53

Answer:
1) Are comprehensive charting forms that integrate assessments and nursing actions

Rationale:
Nursing assessment flow sheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. Graphic information, such as vital signs, I&O, and routine care, may be found on the graphic record. The admission form contains baseline information.

Question 54

At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take?

1) Complete an occurrence report before leaving.
2) Do nothing; the next nurse will document it was done.
3) Write the note of the dressing change into an earlier note.
4) Make a late entry as an addition to the narrative notes.

Answer 54

Answer:
4) Make a late entry as an addition to the narrative notes.

Rationale:
If the nurse fails to make an important entry while charting, she should make a late entry as an addition to the narrative notes. An occurrence report is not necessary in this case. If documentation is omitted, there is no legal verification that the procedure was performed. It is illegal to add to a chart entry that was previously documented. The nurse can only document care directly performed or observed. Therefore, the nurse on the incoming shift would not record the wound change as performed.

Question 55

The client asks the nurse why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system?

1) It includes organizational reports of unusual occurrences that are not part of the client’s record.
2) This type of system consists of combined documentation and daily care plans.
3) It improves interdisciplinary collaboration that improves efficiency in procedures.
4) This type of system tracks medication administration and usage over 24 hours.

Answer 55

Answer:
3) It improves interdisciplinary collaboration that improves efficiency in procedures.

Rationale:
The EHR has several benefits for use, including improving interdisciplinary collaboration and making procedures more accurate and efficient. An occurrence report is an organizational record of an unusual occurrence or accident that is not a part of the client’s record. Integrated plans of care (IPOC) are a combined charting and care plan format. A medication administration record (MAR) is used to document medications administered and their usage.