Exam 15: Documenting and Reporting

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 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?

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? (Select all that apply)

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 administered analgesic medications to an assigned client via central line.In which section of PIE charting should the nurse document this information?

The nurse is teaching medication administration to a client being discharged.Which instruction should the nurse rewrite for this client?

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?

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.Which problem with documentation might have caused the lack of reimbursement?

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 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?

The nurse is documenting client care on flow sheets that identify abnormal assessment findings.Which type of documentation system is the nurse using?

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?

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?

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? (Select all that apply)

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 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?

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? (Select all that apply)

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? (Select all that apply)

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?