Deck 15: Documenting and Reporting

Question 1

Which situation best indicates that the nurse has a good understanding of auditing and monitoring patients' health records?

A)The nurse determines the degree to which standards of care are met by reviewing patients' health records.
B)The nurse realizes that care not documented in patients' health records still qualifies as care provided.
C)The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records.
D)The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment.

Answer 1

The nurse determines the degree to which standards of care are met by reviewing patients' health records.

Question 2

A nurse developed the following discharge summary sheet.Which critical information should be added?
TOPIC: DISCHARGE SUMMARY
Medication
Diet
Activity level
Follow-up care
Wound care
Phone numbers
When to call the doctor
Time of discharge

A)Kardex form
B)Admission nursing history
C)Mode of transportation
D)SOAP notes

Answer 2

Mode of transportation

Question 3

A nurse has taught the patient how to use crutches.The patient went up and down the stairs using crutches with no difficulties.Which information will the nurse use for the "I" in PIE charting?

A)"Patient went up and down stairs."
B)"Deficient knowledge regarding crutches."
C)"Patient demonstrated use of crutches."
D)"Patient used crutches with no difficulties."

Answer 3

"Patient demonstrated use of crutches."

Question 4

A preceptor is supervising a new nurse on documentation.Which situation will cause the preceptor to intervene?

A)The new nurse uses a black ink pen to chart.
B)The new nurse charts consecutively on every other line.
C)The new nurse ends each entry with signature and title.
D)The new nurse keeps the password secure.

Question 5

Which situation will require the nurse to obtain a telephone order?

A)As the nurse and primary care provider leave a patient's room,the primary care provider gives the nurse an order.
B)At 0100,a patient's blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood.
C)At 0800,the nurse and primary care provider make rounds and the primary care provider tells the nurse a diet order.
D)A nurse reads an order correctly as written by the primary care provider in the patient's medical record.

Question 6

A patient is being discharged home.Which information should the nurse include?

A)Acuity level.
B)Community resources.
C)Standardized care plan.
D)Kardex.

Question 7

According to documentation guidelines the most appropriate notation is

A)"1230 hours: Patient's vital signs taken."
B)"0700 hours: Patient drank adequate amount of fluids."
C)"0900 hours: Morphine given for lower abdominal pain."
D)"0830 hours: Increased IV fluid rate to 100 mL per hour."

Question 8

A nurse prepared an audiotaped exchange with another nurse of information about a patient.Which action did the nurse complete?

A)A report.
B)A record.
C)A consultation.
D)A referral.

Question 9

A nurse is giving a hand-off report to the nurse on the next shift.Which information is critical for the nurse to report?

A)The patient had a good day with no complaints.
B)The family is demanding and argumentative.
C)The patient has a new pain medication,hydrocodone bitartrate and acetaminophen (Lortab).
D)The family is poor and had to go on welfare.

Question 10

The final "R" when using the I-SBAR-R communication technique represents which of the following?

A)Recovery.
B)Repeat back.
C)Reorganization.
D)Reintegration.

Question 11

A nurse is charting on a patient's record.Which action is most accurate legally?

A)Charting legibly.
B)Stating that the patient is belligerent.
C)Using correction fluid to correct error.
D)Writing entry for another nurse.

Question 12

A new nurse asks the preceptor why a change-of-shift report is important,inasmuch as care is documented in the chart.What is the preceptor's best response?

A)"A change-of-shift report provides an opportunity to share essential information to ensure patient safety and continuity of care."
B)"A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs."
C)"A change-of-shift report provides an opportunity for the oncoming nurse to ask questions and determine research priorities."
D)"A change-of-shift report provides important information to caregivers and develops relationships within the health care team."

Question 13

A nurse has provided care to a patient.Which entry should the nurse document in the patient's record?

A)"Patient seems to be in pain and states,'I feel uncomfortable.'"
B)"Status unchanged,doing well."
C)"Left abdominal incision 5 cm in length without redness,drainage,or edema."
D)"Patient is hard to care for and refuses all treatments and medications.Family present."

Question 14

A nurse is a member of an interdisciplinary team that uses critical pathways.According to the critical pathway,on day 2 of the hospital stay,the patient should be sitting in the chair.It is day 3,and the patient cannot sit in the chair.What should the nurse do?

A)Focus charting,using the DAR format.
B)Add this observation to the problem list.
C)Document the variance in the patient's record.
D)Report a positive variance in the next interdisciplinary team meeting.

Question 15

A nurse preceptor is supervising a student nurse.Which behaviour by the student nurse will require the nurse preceptor to intervene?

A)The student nurse reviews the patient's medical record.
B)The student nurse reads the patient's plan of care.
C)The student nurse shares patient information with a friend.
D)The student nurse documents medication administered to the patient.

Question 16

A nurse wants to integrate all pertinent patient information into one record,regardless of the number of times a patient enters the health care system.Which term should the nurse use to describe this system?

A)Electronic medical record.
B)Electronic health record.
C)Electronic charting record.
D)Electronic problem record.

Question 17

A nurse is using the source record and wants to find the patient's daily weights.Where should the nurse look?

A)Database.
B)Medical history and examination.
C)Progress notes.
D)Graphic sheet and flow sheet.

Question 18

After providing care,a nurse charts in the patient's record.Which entry should the nurse document?

A)"Appears restless when sitting in the chair"
B)"Drank adequate amounts of water"
C)"Apparently is asleep with eyes closed"
D)"Skin pale and cool"

Question 19

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a productive cough.When is the best time for the nurse to start discharge planning for this patient?

A)Upon admission.
B)Right before discharge.
C)After the congestion is treated.
D)When the primary care provider writes the order.

Question 20

A nurse is preparing a change-of-shift report for a patient who had chest pain.Which information is critical for the nurse to include?

A)"Pupils equal and reactive to light."
B)"The family is a 'pain.'"
C)"Had poor results from the pain medication."
D)"Sharp pain of 8 on a scale of 1 to 10."

Question 21

Which entry will require follow-up by the nurse manager?

A)0800: Patient states,"Fell out of bed." Patient found lying by bed on the floor.Legs equal in length bilaterally with no distortion,pedal pulses strong,leg strength equal and strong,no bruising or bleeding.Neuro checks within normal limits.States,"Did not pass out." Assisted back to bed.Call bell within reach.Bed monitor on.
-------------------Jane More,RN
B)0810: Notified primary care provider of patient's status.New orders received.
-------------------Jane More,RN
C)0815: Portable x-ray of L hip taken in room.Patient states,"I feel fine."
-------------------Jane More,RN
D)0830: Incident report completed and placed on chart.
-------------------Jane More,RN

Question 22

A slight hematoma has developed on the patient's left forearm.The nurse labels the problem as an infiltrated intravenous (IV)line.The nurse elevates the forearm.The patient states,"My arm feels better." When using the DAR notes of focus charting,the nurse would document the "R" as which of the following?

A)"My arm feels better."
B)"Slight hematoma on left forearm."
C)"Infiltrated IV line."
D)"Elevation of left forearm."

Question 23

A nurse is creating a plan to reduce data entry errors and maintain confidentiality.Which guidelines should the nurse include? (Select all that apply. )

A)Create a password with just letters.
B)Bypass the firewall.
C)Use a programmed speed-dial key when faxing.
D)Implement an automatic sign-off.
E)Impose disciplinary actions for inappropriate access.
F)Shred papers containing personal health information.

Question 24

The action that a nurse would take when documenting on the patient's record and notes that he or she has made an error is which of the following?

A)Drawing a line through the error and initialing and dating it.
B)Erasing the error and writing over the material in the same spot.
C)Using a dark-coloured marker to cover the error and continuing immediately after that point.
D)Footnoting the error at the bottom of the page,including initials and the date.

Question 25

A nurse records the following: "Patient is wheezing and experiencing some dyspnea on exertion." This represents which of the following?

A)The "S" in SOAP documentation.
B)Focus documentation.
C)The "P" of PIE documentation.
D)The "R" in DAR documentation.

Question 26

A nurse is discussing the advantages of standardized documentation forms in the nursing information system.Which advantage should the nurse describe?

A)Varied clinical databases.
B)Reduced errors of omission.
C)Increased hospital costs.
D)More time to read charts.

Question 27

A nurse wants to reduce data entry errors on the computer system.Which behaviour should the nurse implement?

A)Use the same password all the time.
B)Share password with only one other staff member.
C)Print out and review computer nursing notes at home.
D)Chart on the computer immediately after care is provided.

Question 28

A nurse obtained a telephone order (TO)from a primary care provider for a patient in pain.Which chart entry should the nurse document?

A)"12/16/20,0915: Tylenol 3,2 tablets,every 6 hours for incisional pain.VO Dr.Day/J.Winds,RN,read back."
B)"12/16/20,0915: Tylenol 3,2 tablets,every 6 hours for incisional pain.TO J.Winds,RN,read back."
C)"12/16/20,0915: Tylenol 3,2 tablets,every 6 hours for incisional pain.TO Dr.Day/J.Winds,RN,read back."
D)"12/16/20,0915: Tylenol 3,2 tablets,every 6 hours for incisional pain.TO J.Winds,RN."

Question 29

A hospital is using computer software that allows all health care providers to use a protocol system to document the care they provide.Which type of system/design will the nurse be using?

A)Clinical decision support system.
B)Nursing process design.
C)Critical pathway design.
D)Computerized provider order entry system.

Question 30

Identify the purposes of a health care record.(Select all that apply. )

A)Communication.
B)Legal documentation.
C)Reimbursement.
D)Education.
E)Research.
F)Nursing process.