Exam 15: Documenting and Reporting

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

The nurse makes chronological entries in a client's chart that include documentation about the routine care provided,assessment findings,and client problems during a 12-hour shift.Which type of charting is this nurse completing?

After completing the client care and documenting it in the progress notes,the nurse realizes that documentation was placed on the wrong medical record.What should the nurse do?

A client's condition has deteriorated and the nurse needs to notify the health care provider.What information should the nurse include when providing a telephone report on this client? Standard Text: Select all that apply.

Before providing care,the nurse reviews the client's pertinent history,daily treatments,diagnostic procedures,allergies,problems,and other information.Which form should the nurse review to learn all of this information?

The nurse works at an organization that is installing a new computerized record system.What should the nurse learn that has been implemented to help ensure the security of client records?

When responding to a call light,the nurse finds a client lying on the floor,with the bed linens around the legs.Which chart entry should the nurse document for this finding?

The nurse is using I-SBAR to provide a report to an intensive care nurse for a client transfer.Which statements indicate that the nurse is using this communication technique appropriately? Standard Text: Select all that apply.

A client in long-term care is scheduled for a review of the assessment and care screening process.Where should the nurse document this information?

A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him,as it's his record.How should the nurse respond to this client's request?

The nurse is documenting care provided to a client.Which action should the nurse take to demonstrate the avoidance of potentially confusing abbreviations when documenting? Standard Text: Select all that apply.

The nurse wants to adhere to practice guidelines that meet legal and ethical standards when documenting client care.Which actions should the nurse take to prove adherence? Standard Text: Select all that apply.

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.Which type of form is this hospital utilizing?

The client states: "I really don't want anyone to visit me who has not been cleared by me first." If utilizing SOAP format,in which category should the nurse document this statement?

The nurse working in a hospital that utilizes a charting by exception (CBE)documentation system notes that a client did not require care in all of the areas identified on a flow sheet.What action should the nurse take?

A client has specific cultural needs that affect the plan of care.In which part of the client's problem-oriented medical record should the nurse document this information?

The nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording.In which section would the nurse find the most recent physician orders?

When attempting to locate recent lab results,the new nurse employee notices that each department has a separate section in the client's chart.Which type of documentation system is the nurse using?

After classroom discussion regarding confidentiality policies and laws protecting client records,a student asks why it's permissible for them to review and have access to client records in the clinical area.How should the nursing instructor respond?

The client had diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack.When utilizing focus charting,in which section should the nurse document this information?