Deck 7: Documentation of Nursing Care

Question 1

Advantages of source-oriented or narrative charting include all of the following except that it:

A) encourages documentation of normal and abnormal findings.
B) gives information on the patient's condition and care in chronological order.
C) indicates the patient's baseline condition for each shift.
D) includes aspects of all steps of the nursing process.

Answer 1

encourages documentation of normal and abnormal findings.

Question 2

The nurse is with a patient who 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 primary care provider requesting that the primary care provider examines the patient for unexpected complications. This documentation by the nurse is likely to:

A) cause the primary care provider 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.

Answer 2

justify insurance reimbursement for an extended duration of hospitalization for the patient.

Question 3

If an agency is using computer-assisted charting, the nurse is responsible for:

A) learning the passwords of the staff nurses and primary care providers so that they can communicate with one another.
B) guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal.
C) patient education to input information about herself, such as intake and output or symptoms the patient may experience.
D) choosing whether he will use the computer to help in documentation or continue to use traditional paper documentation.

Answer 3

guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal.

Question 4

The Quality and Safety Education for Nurses (QSEN) project has identified the most important pre-licensing skills for nurses as:

A) effective communication.
B) informatics.
C) familiarity with medical terms.
D) writing nursing care plans.

Question 5

The nurse understands that a face sheet contains information pertaining to:

A) serial measurements and observations, such as temperature, pulse, respiration, blood pressure, and weight.
B) plan of care for the patient, including nursing diagnoses, goals/expected outcomes, and nursing interventions.
C) written report of the nursing process, record of interventions implemented, and the patient's response to them.
D) patient data, including patient's name, address, phone number, insurance company, and admitting diagnosis.

Question 6

A clinic nurse is documenting in a patient medical record 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) "Periumbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids."

Question 7

Which examples of documentation would be most informative to transcribe to the patient's medical record?

A) "Patient consumed two slices of bread and a cup of coffee at breakfast."
B) "Patient does not appear to be hungry after consuming breakfast."
C) "Patient ate a small amount of bread and drank a little coffee for breakfast."
D) "Patient ate well for breakfast, lunch, and dinner and seems content."

Question 8

A nurse understands that the primary care provider's directives for patient care are also referred to as the:

A) history and physical.
B) primary care provider's orders.
C) progress notes.
D) face sheet.

Question 9

In a medical record 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 documents "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 documentation is an example of:

A) charting by exception.
B) narrative style.
C) a problem-oriented medical record (POMR).
D) the case management system.

Question 10

A nurse begins the shift caring for a patient who has just returned from the recovery room after surgery. It is most important to document:

A) at the end of the shift so that the nurse can give his full attention and time to the patient's needs during the shift.
B) a nursing care plan in the medical record before assessing the patient so that the nurse can identify priorities.
C) at least three times during the shift: at the beginning, in the middle, at the end, and as needed.
D) an initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift.

Question 11

The nurse uses the flow sheet in patient care documentation primarily:

A) to track routine assessments, treatments, and frequently given care.
B) to eliminate written narratives and to save time.
C) in computer-assisted charting to create visual graphs showing change.
D) to improve continuity of care and exchange of information among disciplines.

Question 12

A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to have the medical record to take, 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 medical record, but the medical record is the property of the hospital. I will see about having a copy made for you."
C) "The information in your medical record is confidential, and you cannot leave this facility with it."
D) "Because you are leaving against the medical advice of your primary care provider, you may not have the medical record."

Question 13

In an agency that uses specific protocols (Standard Procedures) and charting by exception, an advantage compared with using traditional (narrative or problem-oriented) documentation 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.

Question 14

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 medical record only after his assigned work is completed.

Question 15

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.

Question 16

When the nurse documents in narrative or source-oriented format about the patient's condition and the nursing care provided, it is appropriate for him to record:

A) "Patient will go to physical therapy after lunch."
B) "Diabetes in excellent control. Continue with current insulin schedule."
C) "I gave the patient a thorough bath and cut her fingernails."
D) "To x-ray by wheelchair at 10:30 AM IV infusing in left arm."

Question 17

A nurse tells her neighbor personal information about a hospitalized patient. Telling her neighbor about this indicates that the:

A) nurse is actively promoting nursing as a profession, and it is important to share information that might encourage others to pursue a nursing career.
B) actions of the nurse are appropriate since his neighbor is his confidante, and the neighbor has assured him the information provided will not be shared.
C) nurse has violated the confidentiality of the patient by discussing personal information about the patient with his neighbor.
D) nurse has not violated the confidentiality of the patient because the patient is terminal; sharing this information will not harm the patient.

Question 18

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."

Question 19

A nurse enters a notation in a patient's medical record 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 located and documents 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.

Question 20

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."

Question 21

Advantages of the problem-oriented medical record (POMR) are that this method of documentation: (Select all that apply.)

A) promotes the problem-solving approach.
B) formats documentation into chronological order.
C) makes tracking trends in patient care easy.
D) allows for easy auditing of patient records to evaluate staff performance.
E) reinforces application of the nursing process.

Question 22

The method of computer-assisted charting: (Select all that apply.)

A) improves communication between departments.
B) is less costly to educate personnel to the method.
C) speeds reimbursement for services.
D) allows electronic records to be retrieved more quickly.
E) allows entries to be made at point of care.

Question 23

The nurse explains that should a patient return to the hospital for treatment within _______ years, the medical record can be retrieved from medical records for review.

Question 24

The electronic medical record was set up as a goal of the Stimulus Law that President Obama signed in 2009, for the purpose of providing a:

A) comprehensive plan of care for all patients.
B) comprehensive record of a patient's history and care across all facilities and admissions.
C) comprehensive document of health care costs.
D) comprehensive plan to allow patient access to medical records.

Question 25

Health care professionals assigned to a patient require access to the medical record to review information and to document care given. All contents of the medical record must be kept ___________. The contents of the medical record should not be discussed with persons who are not involved in the care of the patient.

Question 26

Helpful cultural information the nurse should include on the admission note is: (Select all that apply.)

A) primary language spoken.
B) number of children in the immediate household.
C) beliefs about causality of illness.
D) level of English literacy.
E) dietary concerns.

Question 27

Documentation that follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses' progress notes is _______ charting.

Question 28

When using a case management system of charting a __________, an unexpected event in the patient's condition is documented on the back of the pathway sheets.