nursing fundamentals chapter 5 – Flashcards
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Documentation is a written account of patient care that will be maintained in a chart to serve as a permanent medical record.
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The nurse is educating a student nurse about documentation. The nurse recognizes that additional teaching is required when the student nurse states,
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Documentation is evidence of what transpired during a specific condition or event requiring medical care.
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When documenting in a patient's chart, the nurse recognizes that
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One of the purposes of written documentation is to serve as a legal record for both the patient and the health care provider
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The nurse is educating a student nurse about the purpose of written documentation. The nurse recognizes that additional teaching is warranted when the student nurse states
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For patient care to be effective, it must be delivered and evaluated continuously (not periodically).
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The nurse educates a nursing student about effective patient care. The nurse recognizes that additional instruction is needed when the nursing student states
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The original written or computerized medical record, even though it is about the patient, is the property of the hospital or facility. All of the information within the chart belongs to the patient. The patient is guaranteed by HIPAA the right to view and obtain a copy of the medical record, but the patient does not have the right to take the original chart copy itself. HIPAA ensures the patient's right not only to view and copy his or her own medical record, but also to amend his or her own health information.
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A hospitalized patient tells the nurse that he wishes to take the original chart copy of his medical record home. The nurse's best response is:
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When accidents, incidents, mistakes, or out-of-the-ordinary things occur, the nurse is required to file a written incident, variance, or occurrence report.
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A nurse is caring for a patient who just fell from the bed onto the floor. The nurse should write a(n
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The ideal method to ensure documentation accuracy is to consistently chart immediately after care is provided, when assessment data is obtained, and any event or occurrence that has the potential to affect the patient. The nurse should never chart something before it is done, as this is fraudulent
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The nurse is aware that the best method to ensure documentation accuracy is to consistently chart
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Incident reports are used to document out-of-the-ordinary things that happen in a facility. The incident or occurrence may or may not actually involve a patient. Occurrences that should be documented on an incident or variance report form include the following: medication error; patient injury; visitor injury; employee injury; condition constituting a safety hazard, such as an unsafe staffing situation or failure to repair reported broken or damaged equipment; failure of appropriate health care provider response to an emergency; failure to perform ordered care; loss of patient's personal belongings, prosthetic or assistive devices, home medications, or secured valuables; lack of availability of vital patient care supplies or equipment.
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The nurse teaches a student nurse about what type of occurrence requires completion of an incident report. The nurse recognizes that additional instruction is warranted when the student nurse states
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When completing an incident report or variance report, the nurse should be objective, documenting only what he or she was able to detect with his or her senses: what he or she saw, heard, smelled, or was able to feel with his or her hands. The nurse should avoid interpreting what he or she saw or heard, such as, "Heard the patient fall from the chair to the floor." The statement should be completely objective: "Heard loud crashing sound." Rather than write "Patient fell out of bed," the nurse should document only objective data, such as, "Found patient lying face down on the floor beside the bed" and "Patient reports that he fell out of bed while trying to reach his telephone." The nurse should never document assumptions or drawn conclusions.
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A nurse discovers a patient lying on the floor. When completing an incident report, the nurse should write:
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Many facilities now use military time in an effort to decrease confusion between AM and PM. Military time is not difficult to learn. After 12:00 noon, for the PM hours, one must simply add 12 to the hour. The colon is no longer used and the minutes remain the same. For example, to obtain the military equivalent for 6:00 PM, add 12 to the hour. The time would be 1800.
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A nursing instructor is educating a student nurse about military time. The time is 6:00 PM The student nurse demonstrates understanding by documenting the time as
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When documenting, the nurse should refrain from using subjective terms, such as strange, well, average, normal, bad, poor, odd, or good, because they are vague and mean different things to different people. If the nurse thinks a patient tolerated the clear liquid diet well, he or she should think of the reasons why the patient tolerated it well. Was it because the patient did not experience nausea or vomiting after consumption of the first liquids allowed following NPO? Or was it because the patient with dysphagia, or difficulty swallowing, did not choke or aspirate the liquids? Whatever caused the nurse to think the patient tolerated it well is what should be charted.
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A student nurse is caring for a patient who is on a clear liquid diet. The best example of nursing documentation related to this patient is:
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When charting direct quotations of the patient, the nurse should use his or her exact words and place them in quotation marks. The following is a correct example of charting what the patient said: States "The pain is getting worse. I don't know if I can stand it or not." It would be incorrect to chart what the patient said in the following manner: States "His pain is getting worse and he doesn't know if he can stand it or not."
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A nursing instructor is educating a class of student nurses about patient documentation. The best example of patient documentation is:
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Upon making an incorrect entry, the nurse should mark a single horizontal line through the incorrect word or phrase, write "mistaken entry" and his or her initials just above the incorrect words, and then proceed with the correct entry
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When documenting in a patient's chart, the nurse realizes that it is the wrong patient's chart. The nurse should
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The nurse should avoid using markers or making multiple ink marks in an effort to blacken the incorrect entry so that it cannot be read, as this may raise suspicion regarding the entry.
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The nursing instructor observes a student nurse documenting in the wrong patient's chart. The nursing instructor would intervene when observing the student nurse
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The acronym SOAPIER stands for Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision.
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The nursing instructor educates a class of nursing students about SOAPIER charting. The nursing instructor teaches that the acronym SOAPIER stands for
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The acronym DAR stands for Data, Action, Response.
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The nursing instructor educates a class of nursing students about a common type of focus charting known as DAR. The nursing instructor teaches that the acronym DAR stands for
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The S in SOAPIER stands for subjective data. This information is verbalized by the patient, significant other, or family member. This data is influenced by the person's own personal experiences and perspective, which is what makes it subjective. What was said can be summarized, or exact words can be placed in quotation marks.
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A patient complains of left-sided chest pain radiating to the left shoulder. Using the SOAPIER method, the nurse should chart this complaint under the initial
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The O in SOAPIER stands for objective data. This is for data that is related to the problem. Objective data must be something that the nurse and others are able to discern with one of the senses.
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A patient appears anxious. The patient speaks quickly and paces the hospital halls. Using the SOAPIER method, the nurse should chart this finding under the initial
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The first part of DAR charting is data, which may contain objective or subjective data. For example, the nurse might chart subjective information that the patient's son stated or the patient's verbal complaint of pain. Objective data that the nurse might chart might include the results of pulse oximetry testing, vital signs, or a patient behavior that is observed. Any assessment finding that the nurse detects through use of visual, auditory, olfactory, and tactile senses would be noted under data. These entries represent the data collection and assessment stage of the nursing process
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A patient complains of feeling short of breath. His oxygen saturation level is 86%. When auscultating his lung sounds, the nurse notes wheezes and crackles throughout. The patient has a productive cough of thick green mucus. The nurse should chart these actions under the section of DAR charting that is called
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The second part of DAR charting is action, which is where the nurse charts interventions. Examples might include teaching, repositioning, administering prn medications, changing a dressing, or notifying the physician of an abnormal lab result. These entries reflect the planning and implementing stages of the nursing process.
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When a patient complains of pain, the nurse assesses the pain level and administers an analgesic. The nurse should chart these actions under the section of DAR charting that is called
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Written documentation communicates pertinent data that all health care team members need to provide continuity of care; serves as a record of accountability for quality assurance, accreditation, and reimbursement purposes; provides a permanent record of medical diagnoses, nursing diagnoses, plan of care, care provided, and the patient's response to that care; and serves as a legal record for both the patient and the health care provider.
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A nursing instructor teaches a class of nursing students about the purpose of written documentation, which includes (select all that apply):
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To be accredited by The Joint Commission, a facility must practice in a manner that meets The Joint Commission's standards. This is determined by a team of reviewers who visit the facility to assess its policies, procedures, and actual performance, and who ensure that the standards are met. The Joint Commission sets the standards by which the quality of health care is measured both nationally and internationally. The Joint Commission seeks to improve safety and quality of care that health care organizations provide to the public.
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The staff members at a hospital are preparing for a visit from The Joint Commission. The nursing supervisor explains to the staff that The Joint Commission (select all that apply):
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The original written or computerized medical record, even though it is about the patient, is the property of the hospital or facility. All of the information within the chart belongs to the patient. The patient is guaranteed by HIPAA the right to view and obtain a copy of the medical record, but the patient does not have the right to take the original chart copy itself. HIPPA also gives the patient the right to amend his or her own health information and specify who can obtain this information. HIPAA also requires hospitals to disclose the way in which the patient's health data will be used.
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A nursing instructor is educating a group of student nurses about the Health Insurance Portability and Accountability Act (HIPAA). The nursing instructor teaches that HIPAA (select all that apply):
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Incident reports, also known as variance reports, are used to document out-of-the-ordinary things that happen in a facility. The incident or occurrence may or may not actually involve a patient and is not part of the patient's medical record. Occurrences that should be documented on an incident or variance report form include the following: medication error, patient injury; visitor injury; employee injury; condition constituting a safety hazard, such as unsafe staffing situation or failure to repair reported broken or damaged equipment; failure of appropriate health care provider response to an emergency; failure to perform ordered care; loss of a patient's personal belongings, prosthetic or assistive devices, home medications, or secured valuables; lack of availability of vital patient care supplies or equipment
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The hospital risk management team provides the nursing staff with an in-service about incident reports. The in-service should include that (select all that apply):
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The problem-oriented medical record will have four primary sections: database, problem list, plan of care, and progress notes. Incident reports (also known as variance reports) are not part of the patient's medical record.
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The nursing instructor teaches a class of nursing students that the problem-oriented medical record consists of the (select all that apply):
