Chapter 16: Documenting, Reporting, Conferring and Using Informatics

How could the nurse researcher obtain information from a client record?

The student nurse is reviewing physician orders written on a client's chart. Which entry is written incorrectly because it's on the do not use list of the Joint Commission on Accreditation of Healthcare Organization?

The Joint Commission specifies that nursing care data related to patient assessments, nursing diagnoses, or patient needs, nursing interventions, and patient outcomes, are temporarily integrated into the patient record.

All information about patients is considered private or confidential.

Record patient findings (observations of behavior) rather than [blank_start]your[blank_end] [blank_start]interpretation[blank_end] of these findings.

Document the [blank_start]nursing[blank_end] [blank_start]response[blank_end] to questionable medical orders or treatment (or failure to treat). Factually [blank_start]record[blank_end] the [blank_start]date[blank_end] and [blank_start]time[blank_end] the physician was notified of the concern and the exact physician response. If a nurse administrator was contacted, document this.

Never document interventions before carrying them out

You can skip lines when documenting.

Draw a double line through blank spaces.

Sign your [blank_start]first[blank_end] [blank_start]initial[blank_end], [blank_start]last[blank_end] [blank_start]name[blank_end] and [blank_start]title[blank_end] to each entry.

Draw a [blank_start]single[blank_end] [blank_start]line[blank_end] through an incorrect entry, and write the words [blank_start]mistaken[blank_end] [blank_start]entry[blank_end] or [blank_start]error[blank_end] [blank_start]in[blank_end] [blank_start]charting[blank_end], above or beside the entry and sign. Then rewrite the entry correctly.

Actual patient names and other identifiers should not be used in written or oral student reports.

To release a patient's health information for purposes other than [blank_start]treatment[blank_end], [blank_start]payment[blank_end] or routine [blank_start]health[blank_end] [blank_start]care[blank_end] operations. the patient must be asked to sign an [blank_start]authorization[blank_end].

An [blank_start]information[blank_end] [blank_start]officer[blank_end] or [blank_start]clinical[blank_end] [blank_start]informaticist[blank_end] can help with knowing your agency's policies regarding the patient's rights to accessing record.

The only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a [blank_start]medical[blank_end] [blank_start]emergency[blank_end]. The order must be given directly by the physician or nurse practitioner to a registered professional nurse or pharmacist, who [blank_start]receives[blank_end], [blank_start]read[blank_end] [blank_start]back[blank_end], [blank_start]documents[blank_end], and [blank_start]executes[blank_end] the order.

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with a diagnosis of appendicitis. The physician has ordered 10 mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follows recommended guidelines?

A nurse is documenting the care given to a 56 year old patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing change was performed on the left leg. What would be the best action of the nurse to correct this documentation?

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response?

According to HIPPA, if a health institution wants to release a patient's health information for purposes other than treatment, payment and routine health care operations, the patient must be asked to sign an authorization. The nurse is aware that there are exceptions to this requirement. In which of the following cases is an authorization form not needed?

A friend of a nurse calls and asks if she is still working at Memorial Hospital. The nurse replies "Yes". The friend tell the nurse that his girlfriend's father was just admitted as a patient and he wants the nurse to find out how he is. The friend states "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her" What is the best initial response the nurse should make?

A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication?

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the physician's order sheet. The nurse's best response is

A nurse is looking for trends in a postopertive patient's vital signs. Which documents would the nurse consult first?

A nurse is using the SOAP format of documentation to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation?

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a male patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Label the following correctly: [blank_start]Situation[blank_end]: I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer [blank_start]Assessment[blank_end]: Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump [blank_start]Read-back of orders/response[blank_end]: You want me to discontinue the PCA pump until you see him tonight at patient rounds [blank_start]Identity/Introduction[blank_end]: I am Rosa Clark, an RN working on the second floor of South Street Hospital [blank_start]Background[blank_end]: Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer [blank_start]Recommendation[blank_end]: I think the dosage of morphine in Mrs. Sanchez's PCA pump needs to be lowered

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest?

A nurse on the night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

A physician suggests that a nurse use the computer terminal that is available at the point of care or at the client's bedside. What is the probable reason for the physician's suggestion?

How can the nurse researcher obtain information from a client record?

A group of nurses have established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of what?

When maintaining medical records for a client, the nurse knows that a medical record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?

A healthcare facility plans to evaluate and revise the plan of care for a client based on the client's medical records. The physician, dietician, and the nurse involved in the client's care are required to collate all of the information for easy access. Which style do you think the agency is following in order to record the client details?

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note, in a short-hand method using well-defined standards practice. Which of the following best defines this type of charting?

Which of the following information about the patient would a nurse include as part of a minimum data set when using electronic medical records?

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?

The nurse should utilize ISBARR communication during which of the following clinical situations?

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?