Chapter 7: Documentation of Nursing Care – Flashcards

The nurse with a patient complains of severe pain documents every 15 minutes about the steps taken to try to relieve the pain (without success). The nurse also documents the time and content of two calls made to the patient's physician requesting that the position examine the patient for unexpected complications. This documentation by the nurse is likely to do: A. Cause the physcian to come to the attention of the hospital administration B.be questioned by the nurse's supervisor for time inefficiency C. Be used against the nurse if a lawsuit results, because it proves the nurse was not able to relieve the pain. D. Justify insurance reimbursement for an extended duration of hospitalization for the patient

A patient who is very angry and is leaving the hospital against medical advice(AMA) demands to have the medical chart because it is her personal property. An appropriate response would be: A. "Certainly. This hospital doesn't need to keep it if you are leaving and will not be returning here" B. "You are entitled to the information in your chart, but the chart is the property of the hospital. I will see about having a copy made for you" C. "The information in your chart is confidential, and you cannot leave this facility with it" D. "because you are leaving against medical advice of your physician, you may not have the chart"

A student nurse is assigned to a clinical unit on which one of the patients is a nationally known celebrity. The student reads the chart to find out why the celebrity is being treated. The student who is not the assigned caregiver is: a. motivated to learn about the health problem of this patient and is appropriately seeking knowledge during his clinical experience. b. doing appropriate research about nursing care as long as information is not divulged. c. violating the confidentiality of the patient's record. d. neglecting the assigned patient load and should read the unassigned patient's chart only after his assigned work is completed

A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced by disruption of skin surface has the following nursing documentation: "Incision clean, dry, intact. No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from clothing. Verbalizes understanding of wound care and ability to manage at home. Wound healing without complication." This documentation is: a. an example of charting by exception. b. evidence of the use of the nursing process. c. using the problem-oriented medical record (POMR) format. d. usually entered on a flow sheet for treatments and vital signs.

Which nursing assessment is an example of brevity and clarity while meeting legal guidelines? . A. "4 cm reddened area over sacrum. Skin intact, warm, and dry." b. "Taking fluids poorly, but more than yesterday." c. "Apparently comfortable all night. Offers no complaints of pain." d. "Patient says she is still slightly nauseated, would like to try some toast and tea."

A nurse enters a notation in a patient's chart but then discovers that the notation was made in the wrong chart. The nurse correctly: A. draws a single line through the notation so that it is still readable and writes "mistaken entry," his signature, and the date and time. B. removes the page on which the error is written and rewrites the other correct notes. C. blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin "wrong patient," his signature, and the date and time. D. whites out the wrong entry and writes the note in the chart of the correct patient

A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says to the nurse, "I don't want to have you draw any more blood for those useless tests." When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be: a. "Refuses to have blood drawn. Doctor notified." b. "Refuses to have blood drawn; says tests are 'useless.' Doctor notified." c. "Doctor notified of failure to draw ordered blood work." d. "Blood not drawn because tests are no longer desired by patient."

A clinic nurse is documenting in a patient chart about the pain that brought the patient to seek medical attention. The best description is: a. "Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch." b. "Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch." c. "Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse." d. "Peri-umbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids."

In a chart for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired, related to allergic reaction as evidenced by rash and hives, the nurse charts "Subjective: denies itching. Happy with improvement in skin. Objective: rash fading on face, chest, and back; no hives visible on skin. Skin warm, dry, and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge." This type of charting is an example of: a. charting by exception. b. narrative style. c. a problem-oriented medical record (POMR). d. The case management system.

In an agency that uses specific protocols (Standard Procedures) and charting by exception, an advantage compared with using traditional (narrative or problem-oriented) charting is that charting by exception: a. is well suited to defending nursing actions in court. b. contains important data certain to be noted in the narrative sections. c. allows staff to learn the system quickly and easily. d. highlights abnormal data and patient trends.