48.4 Posttest Documentation and Reporting- Nursing concepts MNL – Flashcards

A nurse is documenting client information into the database of a​ problem-oriented medical record. Which client information is the nurse likely​ documenting? Health history This is the correct answer. Nursing diagnosis Plan of care Your answer is not correct. Spiritual needs Review Only Learning Objective Compare different systems and approaches used to document client care. Rationale The database of a​ problem-oriented medical record​ (POMR) consists of all information known about the client when the client first enters the healthcare​ agency, including the​ client's health history. The spiritual needs of the client and the nursing diagnosis are documented in the problem list of the POMR. The plan of care has its own section in the POMR.

A novice nurse is hired to work on the telemetry unit and is reviewing the unit​'s policy on handoff communication and the use of the SHARE method. What is true regarding this​ method? ​(Select all that​ apply.) a. It provides opportunity to ask questions during the transfer. This is the correct answer. b. It ensures that the nurse provides the essential content during the transfer. Your answer is correct. c. It ensures that the nurse uses his own narrative and charting during the transfer. d. It provides timely feedback to staff who fail to follow the process. This is the correct answer. e. It provides standardized training in the handoff process. Your answer is correct. Review Only Learning Objective Summarize the​ purpose, types, and steps of verbal or written reporting systems. Rationale One strategy that can be used to ensure a successful handoff is using the SHARE method. The steps of this method ​are:Standardize critical ​content;Hardwire within your ​system;Allow opportunity to ask ​questions;Reinforce quality and ​measurement;Educate and coach. Hardwiring involves the use of standardized​ forms, such as​ checklists, and methods of conducting a successful handoff. These standardized forms are used instead of the​ nurse's narrative. All other answer choices are true of this method.

A nurse working in the intensive care unit​ (ICU) needs to give a​ change-of-shift report. What is the most appropriate action by the nurse for this type of verbal reporting​ system? a. Give details on routine care needs of the client b. Elaborate on client background data c. Report a client​'s need for special emotional support d. State priorities of client care at the beginning Your answer is not correct. Rationale During a​ change-of-shift report, the nurse should include the​ client's need for special support. The nurse should be concise and brief regarding client background data and routine care needs of the client. Priorities of client care should be stated at the end of the​ report, when the receiving nurse will be most likely to remember the information.

A nurse decides to add narrative charting to the client​'s nursing progress note to make a more complete nursing progress note. The nurse​ writes, open double quote "The client wasn​'t hungry and didn​'t eat much. close double quote " What document guideline is the nurse failing to​ use? a. Sequence b. Appropriateness c. Conciseness d. Accuracy Rationale The nurse is failing to document accurately. In order to adhere to this​ guideline, the nurse must document facts or​ observations, not opinions or interpretations. Documenting events in the order in which they occur is adhering to sequencing. Appropriateness refers to documenting facts regarding the client​ condition, not personal information that is not related to client care. Conciseness is thorough but brief documentation.

A nurse educator is teaching a group of student nurses about correct documentation techniques. Which statements are appropriate for the nurse educator to include in the teaching​ session? ​(Select all that​ apply.) a. ​"Document the​ client's response to​ interventions." Your answer is correct. b. ​"Follow organizational policies to correct charting​ errors." This is the correct answer. ​ c. "Do not document the​ client's actual​ words." d. ​"Document in a timely​ manner." Your answer is correct. e. ​"Use subjective and thorough​ descriptions." Rationale Nurses should document the​ client's response to​ interventions, follow organizational policies to correct charting​ errors, and document in a timely manner. The nurse should document the​ client's actual words using quotation marks around the client statement. Documentation should be​ objective, not subjective.

A student nurse is performing a clinical rotation and needs to access client information for an assignment at school. In which situations is it appropriate for the student nurse to have access to client​ information? ​(Select all that​ apply.) a. When participating in clinical rounds Your answer is correct. b. When presenting client studies Your answer is correct. c. When writing papers This is the correct answer. d. When presenting for clinical conferences Your answer is correct. e. When studying for exams Rationale Student nurse access to client information can be for written​ papers, clinical rounds and​ conferences, and client studies. Having access to client information to use as study materials is not appropriate for the student nurse.

A nurse is documenting client protected health information​ (PHI) at a point of care computer terminal in the client​'s room. Keeping in mind that the client​'s room is​ private, which action by the nurse is acceptable regarding protecting the client​'s PHI once the nurse leaves the client​'s ​room? a. Minimizing the client​'s PHI on the screen but remaining logged in b. Exiting out of the client​'s PHI and logging off c. Exiting out of the client​'s PHI but remaining logged in d. Remaining logged in to the computer because the client​'s room is private Rationale To best protect the​ client's PHI, the nurse must exit out of the​ client's PHI and log off of the​ computer, regardless of the degree of privacy of the​ client's room.

A nurse is participating in a committee that will select a universal nursing documentation for the hospital. What advantages would the committee consider when looking at the focus charting documentation​ format? ​(Select all that​ apply.) a. Offers a complete perspective of the client and the client​'s care needs. Your answer is correct. b. Ensures that the nursing focused assessment is the priority of care. c. Ensures that each nursing note includes​ data, action, and response. d. Provides a structure for the progress notes. Your answer is correct. e. Allows for checklists or flow sheets to record routine nursing tasks. Your answer is correct. Review Only Learning Objective Compare different systems and approaches used to document client care.