Exam 16: Documenting and Reporting

Documentation of nursing care is particularly relevant for the long-term care settings because:

A client did not meet the goal of walking unassisted without assistive devices by discharge from rehabilitation. The case manager using a critical pathway would identify this as which of the following?

A client's data that is arranged according to the problems the client has, rather than the source of the information, is recorded in the:

Charting that is intended to make the patient and patient concerns and strengths the focus of care is referred to as:

A client who has been hospitalised for a period of time is now being transferred to a rehabilitation centre for more long-term care. As he is preparing to be discharged, the client asks the nurse if he can take his chart with him, since it's his record. The nurse responds correctly by saying:

In what way is a patient's information and record protected?

At the end of the shift, the nurse is reviewing client documentation for the shift. Among the documentation entries the nurse checks, special attention is paid to the flow sheets and abnormal assessment findings for each client. This type of charting is an example of which of the following?

A nurse makes an entry in a client's chart that includes documentation about the routine care, assessment findings, and client problems. This documentation is arranged in a chronological order, from the time the nurse started the shift until the nurse entered the documentation in the client's record. This is an example of which of the following?

The difference between "acute care" and "home care" client records is:

A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. This hospital is utilising which of the following?

The nurse administered analgesic medications to an assigned client via central line. This information should be documented in which section if using PIE charting?

Which of the following is not a key element of a handover report?

A nurse is reviewing a client's chart in a facility that utilises problem-oriented recording. In looking for the most recent physician orders, the nurse should look in which section?

After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why it's okay for the students to review and have access to client records in the clinical area. The nurse educator responds correctly by stating that:

After completing the clinical and documenting in the progress notes, the nursing student discovered he had written in the wrong chart. The correct action is to:

A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. A problem in documentation that may have caused the lack of reimbursement would be which of the following?

A nursing student has been assigned to a specific client for one of the clinical experiences on a surgical unit. Before the clinical experience begins, the student must be aware of the client's pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information in order to provide the most appropriate care during the shift. In order to help the student save time in researching all of this information, what should be the first place to start the review?

The nurse is doing teaching regarding medication administration for a client who is being discharged. Which of the following instructions are correctly rewritten for this client?

An example of legally defensible charting would be: