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Who may access a client's medical record?

Only those health care
providers who are involved directly in a client’s care may access that client’s medical record.


Information to document


Medication administration

Treatments and responses

Client education


Purposes for medical records include:

communication, legal documentation, financial billing,
education, research, and auditing.


Subjective Data Documentation

direct quotes, within quotation marks, or summarize
and identify the information as the client’s statement.


Objective Data Documentation

Is descriptive and should include what the nurse sees, hears, feels, and


Documentation should include:

Assessments, interventions, and evaluations, not personal opinions or criticism of others’ care.


Narrative Documentation

records information as a sequence of events in a storylike manner.


Charting by exception

standardized forms that identify norms and allows selective
documentation of deviations from those norms.


SOAP notes

S – Subjective data
O – Objective data
A – Assessment (includes a nursing diagnosis based on the assessment)
P – Plan


PIE notes

P – Problem
I – Intervention
E – Evaluation


DAR (Focus Charting)

D – Data
A – Action
R – Response


End of Shift Report Includes

Significant objective information about the client’s health problems.

Proceed in a logical sequence.

Include no gossip or personal opinion.

Relate recent changes in medications, treatments, procedures, and the discharge plan.



Health Insurance Portability and Accountability Act of 1996



protected health information


A nurse is preparing information for change-of-shift report. Which of the following information should
the nurse include in the report?

A. The client’s input and output for the shift

B. The client’s blood pressure from the previous day

C. A bone scan that is scheduled for today

D. The medication routine from the medication administration record

C. is CORRECT: The bone scan is important because the nurse might have to modify the client’s care to accommodate leaving the unit.


A nurse enters a client’s room and finds him sitting in his chair. He states, “I fell in the shower, but I got myself back up and into my chair.” How should the nurse document this in the client’s chart?

A. The client fell in the shower.

B. The client states he fell in the shower and was able to get himself back into his chair.

C. The nurse should not document this information in the chart because she did not witness

the fall.

D. The client fell in the shower but is now resting comfortably.

B. is CORRECT: By writing what the client states, the information is subjective data.


A nursing instructor is reviewing documentation with a group of nursing students. Which of the

following legal guidelines should they follow when documenting in a client’s record? (Select all

that apply.)

A. Cover errors with correction fluid, and write in the correct information.

B. Put the date and time on all entries.

C. Document objective data, leaving out opinions.

D. Use as many abbreviations as possible.

E. Wait until the end of the shift to document.

B. and C. are CORRECT:
The day and time confirm the recording of the correct sequence of events.

Documentation must be factual, descriptive, and objective, without opinions or criticism.


The skin barrier covering a client’s intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the current shift, but it remains intact only when the client is
supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage
from the fistula, so the therapist did not ambulate the client today. The client sat in a chair during lunch with an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having
physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? (Select all that apply.)

A. The physical therapist did not ambulate the client today.

B. The skin barrier’s seal stays on in bed but loosens when the client stands.

C. The client seemed to welcome having a “day off” from physical therapy.

D. The wound care nurse will see the client later today.

E. The client ate all the food on her lunch tray.

A. B. and D. are CORRECT: The oncoming nurse needs to know about any changes in or deviations from the
client’s plan of care, such as missing a physical therapy session.

The current problem about the adhesion of the skin barrier is important information the oncoming nurse needs to know and address.

The oncoming nurse needs to know about any consultations that will take place during the shift.


A nurse is receiving a provider’s prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.)

A. Repeat the details of the prescription back to the provider.

B. Have another nurse listen to the telephone prescription.

C. Obtain the prescriber’s signature on the prescription within 24 hr.

D. Decline the verbal prescription because it is not an emergency situation.

E. Tell the charge nurse that the provider has prescribed morphine by telephone.

A., B. and C. are CORRECT: The nurse should repeat the medication’s name, dosage, time or interval, route, and any other pertinent information back to the provider and receive and document confirmation.

Having another nurse listen to the telephone prescription is a safety precaution that helps prevent medication errors due to miscommunication.

The provider must sign the prescription within the time frame the facility specifies in its policies (generally 24 hr).



Absence of illness-producing micro-organisms.
Maintained through aseptic technique (primarily hand hygiene)
Two types - medical & surgical asepsis


Before beginning any task or procedure that requires aseptic technique, health care team
members must check for ____________.

latex allergies


When should nurse use hand hygiene?

Before and after every client contact
After removing gloves
After contact with body fluids
After using the restroom.
Use soap & water for visibly soiled hands


Administering oral medication, managing nasogastric tubes, providing personal hygiene, and performing many other common nursing tasks.

Would you use Medical or Surgical Asepsis?

Medical Asepsis


Parenteral medication administration, insertion of urinary catheters, surgical procedures, sterile dressing changes, and many other common nursing procedures.

Would you use Medical or Surgical Asepsis?

Surgical Asepsis


No. 1 measure to reduce the growth and transmission of infectious agents

Hand hygiene


Surgial Asepsis

The use of precise practices to eliminate all micro-organisms from an object or area.
“Sterile technique”


Hand Hygiene Includes

Handwashing with an antimicrobial or plain soap and water
Alcohol based products such as gels, foams, and rinses


Three essential components to handwashing



Medical Asepsis

The use of precise practices to reduce the number, growth, and spread of micro-organisms from an object, person, or area.
"Clean technique"


When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse

A. keep the sterile field at least 6 ft away from the client’s bedside.

B. instruct the client to refrain from coughing and sneezing during the dressing change.

C. place a mask on the client to limit the spread of micro-organisms into the surgical wound.

D. keep a box of facial tissues nearby for the client to use during the dressing change.

C. CORRECT: Placing a mask on the client prevents contamination of the surgical wound during the
dressing change.