Potter & Perry Ch 26 Documentation Review Questions

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note?

1. Avoid rushing when charting an entry

2. Use correction fluid to remove the entry

3. Draw a single line through the statement and initial it

4. Enter only objective and factual information about the patient

4. Enter only objective and factual information about the patient

Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record.

A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse:

1. Uses SBAR as a format when providing the report

2. Gives a newly ordered medication before entering the order in the patient's medical record

3. Reads the orders back to the health care provider after receiving them and verifies their accuracy

4. Asks the preceptor to listen in on the phone conversation

2. Gives a newly ordered medication before entering the order in the patient's medical record

Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur.

As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status?

1. The patient has a defiant attitude and is demanding his test results

2. The patient appears to be upset with his nurse because he wants his test results immediately

3. The patient is demanding and complains frequently about his doctor

4. The patient stated that he felt frustrated by the lack of information he received regarding his tests.

4. The patient stated that he felt frustrated by the lack of information he received regarding his tests.

Answer 4 is a nonjudgmental statement regarding the nurse's observations about the patient. Answers 1 and 3 are judgmental, and information in the medical record should be factual and nonjudgmental. Answer 2 needs to be more specific regarding the reason for the patient's concern.

You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response?

1. HIPAA allows all hospital staff access to your medical record

2. HIPAA limits the information that is documented in your medical record

3. HIPAA provides you with greater control over your personal health care information

4. HIPAA enables health care institutions to release all of your personal information to improve continuity of care

3. HIPAA provides you with greater control over your personal health care information

HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patient's medical record.

A patient asks for a copy of her medical record. The best response by the nurse is to:

1. State that only her family may read the record

2. Indicate that she has the right to read her record

3. Tell her that she is not allowed to read her record

4. Explain that only health care workers have access to her record

2. Indicate that she has the right to read her record

Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission.

Which of the following charting entries is most accurate?

1. Patient walked up and down hallway with assistance, tolerated well

2. Patient up, out of bed, walked down hallway and back to room, tolerated well

3. Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during walk

4. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise

4. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise

Answer 4 provides the most accurate, objective information for the chart.

Match the correct entry with the appropriate SOAP category.

a. Repositioned patient on right side. Encouraged patient to use patient controlled analgesia (PCA) device.

b. "The pain increases every time I try to turn on my left side."

c. Acute pain related to tissue injury from surgical incision

d. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation

S - b. "The pain increases every time I try to turn on my left side."

O - d. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation

A - c. Acute pain related to tissue injury from surgical incision

P - a. Repositioned patient on right side. Encouraged patient to use patient controlled analgesia (PCA) device.

On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. The type of feature is most common in what type of record system?

1. Information technology

2. Electronic health record

3. Personal health information

4. Administrative information system

2. Electronic health record

This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting. In this question you are able to access information about the patient from the current hospitalization and from four previous times when the patient accessed care.

You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.)

1. The patient's name, age, and admitting diagnosis

2. Allergies to food and medication

3. Your evaluation that the patient is "needy"

4. How much the patient ate for breakfast

5. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol

1. The patient's name, age, and admitting diagnosis

2. Allergies to food and medication

5. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol

During change of shift report, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include response to treatments such as response to pain-relieving measures. Information about how much the patient ate for breakfast is not necessary. This information is in the chart if the nurse really needs to know. Do not include critical comments about your patients.

You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student:

1. Documented medication given by another nursing student

2. Included the date and time of all entries in the chart

3. Stood with his back against the wall while documenting on the computer

4. Signed all documentation electronically

1. Documented medication given by another nursing student

Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed.

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE?

1. "CPOE reduces transciption errors."

2. "CPOE reduces the time necessary for health care providers to write orders."

3. "Health care providers can write orders from any computer that has Internet access."

4. "CPOE reduces the time nurses use to communicate with health care providers."

1. "CPOE reduces transciption errors."

CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly.

You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet?

1. The new federal laws require that teaching sheets be emailed to patients after they are discharged

2. You need to use words the patients can understand when writing directions

3. The form needs to be given to patients in a sealed envelope to protect their health information

4. The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home

2. You need to use words the patients can understand when writing directions

Patients need to be able to understand information that you provide to them; ensure that written instructions are provided at a level that matches the patients' reading ability.

A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at high risk for aspiration because the head of the bed is not elevated high enough. The warning is known as what type of system?

1. Electronic health record

2. Clinical documentation

3. Clinical decision support system

4. Computerized physician order entry

3. Clinical decision support system

A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user.

While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because:

1. The nurses forgot to document on the pulmonary system

2. The nurses were charting by exception

3. The computer is not working correctly

4. The physician does not have authorization to view the nursing assessment

2. The nurses were charting by exception

Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits.

What is an appropriate way for a nurse to dispose of printed patient information?

1. Rip several times and place in a standard trash can

2. Place in the patient's paper-based chart

3. Place in a secure canister marked for shredding

4. Burn the documents

3. Place in a secure canister marked for shredding

Confidential patient information should be shredded. It is generally collected in large secure containers and shredded at scheduled times.