Deck 16: Documenting and Reporting

Question 1

The client, after receiving emergency treatment for an acute asthma attack, had diminished wheezing in both lungs. When utilising focus charting, this information would be included in the ________ section.

Answer 1

response

Question 2

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) An incorrectly written care plan.
B) An error in judgment on the case manager's part.
C) A variance.
D) An unattainable goal.

Answer 2

A variance.

Question 3

A nurse works in a hospital that utilises a charting by exception documentation system. When providing care and performing assessments, the nurse may not address all of the sections on a client's flow sheet, especially if the client did not require this particular care. In order for the nurse to identify that these areas were addressed, but no care was needed, the best action is to:

A) write "N/A" on the flow sheet in the areas that are not applicable rather than leave blank spaces.
B) leave them blank, but then add an extensive explanation in the progress notes section of the chart.
C) make sure this information gets passed along in the shift report.
D) leave them blank.

Answer 3

write "N/A" on the flow sheet in the areas that are not applicable rather than leave blank spaces.

Question 4

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?

A) The written care plan.
B) The MAR (medication administration record).
C) The client's medical record.
D) The progress notes.

Question 5

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?

A) Source-oriented recording.
B) Narrative charting.
C) Problem-oriented recording.
D) Plan of care.

Question 6

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) Focus charting.
B) Charting by exception.
C) SOAP charting.
D) Computerised documentation.

Question 7

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

A) focus charting.
B) charting by exception.
C) progress notes.
D) problems, interventions and evaluation charting.

Question 8

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?

A) Progress notes.
B) Medical care plan.
C) Database.
D) Problem list.

Question 9

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:

A) "Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence."
B) "As long as the clinical instructor is in the area, accessing client records is part of the education process."
C) "Most students review so many records and charts that they could not possibly remember details from any one of them."
D) "Confidentiality and privacy laws don't apply to students."

Question 10

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:

A) "You'll have to ask your doctor for permission to do that."
B) "There's a new law that protects your records, so you're not going to be able to have access to them."
C) "Actually, the original record is the property of the hospital, but you are welcome to have copies of your records."
D) "We'll make sure that all of your records are sent ahead to the rehab hospital, so you don't really have to worry about those details."

Question 11

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

A) older people at home do not require many nursing interventions.
B) home care does not require such in-depth documentation.
C) the doctor's records are separate to the nursing record.
D) access to the technology is not available.

Question 12

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?

A) Traditional care plans.
B) Critical pathways.
C) Standardised care plans.
D) Flow sheet plan.

Question 13

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

A) As a contract between the client and the hospital.
B) As a contract between the client and the nurse.
C) As a contract between the client and the doctor.
D) By law.

Question 14

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

A) these clients aren't as sick as the hospital ones.
B) evidence for funding is based on care given.
C) it needs to meet a particular standard.
D) it is much more informal than acute care.

Question 15

A student nurse is reviewing an assigned client's chart. When trying to locate recent lab results, the student notices that each department has a separate section in the chart. This type of documentation system is called which of the following?

A) Case management.
B) Focus charting.
C) Problem-oriented record.
D) Source-oriented record.

Question 16

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:

A) ACHS.
B) POMR.
C) CBE.
D) PIE.

Question 17

A client has specific cultural needs in regard to the plan of care. The facility uses narrative charting. This information would be found in which of the following?

A) Progress notes.
B) Database.
C) Plan of care.
D) Problem list.

Question 18

The client states: "I really don't want anyone to visit me who has not been approved by me first". If utilising SOAP format, this statement would be documented under which category?

A) Planning.
B) Subjective data.
C) Assessment.
D) Objective data.

Question 19

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) The client's record contained an incorrect DRG.
B) The client was charged for medications the client did not use.
C) The client was charged for an ECG.
D) The physician made a diagnostic mistake.

Question 20

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

A) Plan.
B) Progress notes.
C) Interventions.
D) Evaluations.

Question 21

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

A) Changes in a patient's condition and present status.
B) Usual social support visitors.
C) Needs for special emotional support.
D) Reasons for admission and summary of priorities.

Question 22

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) take a wide permanent marker and blacken out all the documentation.
B) draw a single line through the documentation, write "mistaken entry" next to the original entry, and initial it.
C) put an "X" through the entire page, identify it as an "error" initial it, and move on to the correct chart.
D) use white-out over the mistake.

Question 24

An example of legally defensible charting would be:

A) "Appears to be sleeping well."
B) "Patient complains all the time."
C) "Patient slept normally."
D) "Easily aroused from sleep."

Question 25

Match the following terms related to documentation with its relevant description (only one response for each).
1. Accuracy
2. Sequence
3. Appropriateness
4. Completeness
5. Conciseness
6. Legal prudence
A. Care delivered and omitted
B. Demeaning and derogatory entries
C. Occurs in a specific order
D. Consists of facts and objective data
E. Proof of quality of care
F. Brief without naming patient

Question 26

The use of abbreviations is limited because:

A) most people can understand them.
B) it makes charting quicker and easier.
C) there is confusion if there is more than one meaning.
D) there is no list of common meanings.

Question 27

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?

A) Lasix, 20 mg, po bid.
B) Lasix, 20 mg, po twice daily.
C) Lasix, 20 mg by mouth 8 a.m. and 2 p.m.
D) Lasix, 20 mg by mouth, twice a day.