Deck 4: Reporting and Recording

Question 1

Nurse Smith gave a report to Nurse Jones and went home.After getting home,Nurse Smith remembered that she gave the patient morphine 2 mg IV but forgot to chart it in the progress note.She calls Nurse Jones to let her know and asks if Nurse Jones could chart it for her.Nurse Jones should:

A) Thank Nurse Smith for calling, but refuse to chart a medication that she did not give
B) Chart that Nurse Smith called and reported that the medication was given at the time given and why
C) Chart that the medication was given and sign the entry as Nurse Smith
D) Chart that the medication was given and leave a blank spot for Nurse Smith to sign when she returns

Answer 1

Chart that Nurse Smith called and reported that the medication was given at the time given and why

Question 2

Of the following documentation systems,which involves writing a narrative note only when there is a change from an established norm?

A) SOAP
B) SBAR
C) Focus charting
D) Charting by exception

Answer 2

Charting by exception

Question 3

The patient is ready to go home from the hospital.Prior to his leaving,the nurse provides the patient and family with a:

A) Discharge summary
B) Standardized care plan
C) Patient care summary
D) Flow sheet

Answer 3

Discharge summary

Question 4

The nurse manager is attempting to determine the staffing needs of the unit.One tool that she may use to determine the level of care needed would be:

A) The standardized care plan
B) The acuity record
C) The patient care summary
D) Flow sheets

Question 5

The patient is a 24-year-old man who is diagnosed with possible HIV infection while being treated for active pneumonia.He has stated that the nurse may share test result information with his significant other but nothing else at this time.The nurse may:

A) Update the patient's parents as well
B) Update the patient's significant other only
C) Update no one in the hospital until the patient says so
D) Update the patient's physician, significant other, laboratory personnel

Question 6

A preprinted guideline used to care for patients with similar health problems is known as:

A) The acuity record
B) The standardized care plan
C) The patient care summary
D) The flow sheet

Question 7

The patient was in bed with all side rails up.During the night,the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails.After meeting the patient's needs and assessing that the patient is not harmed,the nurse needs to:

A) Complete an incident report and put it in the medical record
B) Chart what happened and state that an incident report has been filled out
C) Do nothing since the patient was not harmed
D) Document what happened in the patient record without mentioning the incident report

Question 8

One primary difference between home care and hospital care is that with home care:

A) Documentation systems need to provide information for the home health nurse only
B) Documentation no longer affects reimbursement
C) Services are assumed and need less documentation
D) The patient and the family witness the majority of the care provided

Question 9

The patient has a student nurse from Anyplace College (AC)caring for him this morning.On this unit,student nurses are not allowed to chart on their patient.The nurse should:

A) Chart that AM care was given and sign her name and title
B) Not chart that AM care was given since she did not provide it
C) Chart that AM care was given by the student nurse
D) Chart that AM care was given by Suzie Newnurse, SN, AC

Question 10

Which of the following is the best example of accurate documentation?

A) "Abdominal wound is 5 cm in length without redness, edema, or drainage."
B) "OD to be irrigated qd with NS."
C) "No complaint of abdominal pain this shift."
D) "Patient watching TV entire shift."

Question 11

The nursing assistant tells the RN that when the patient's vital signs were taken,the patient complained that she was in a lot of pain.The nursing assistant then tells the nurse that she charted the patient's complaint when she charted the vital signs.The nurse needs to instruct the nursing assistant that:

A) She is thankful that the assistant charted all that, so the RN does not have to
B) Nursing assistants are not allowed to chart vital signs
C) Only the nurse can write in the progress notes
D) The nursing assistant needs to write using blue ink to distinguish from the RN note

Question 12

The patient has been in the hospital for 12 days.The nurse meets with the physical therapist,the case manager,the nutritionist,and other members of the team to discuss his progress and readiness to go home.This type of multidisciplinary meeting often is called:

A) A handoff report
B) A discharge planning conference
C) A verbal report
D) A transfer report

Question 13

A delivery model that coordinates and links health care services to patients and families is:

A) Critical pathways
B) Charting by exception
C) SOAP
D) Case management

Question 14

The documentation method that focuses on the patient's problems is known as:

A) Narrative documentation
B) The problem list
C) The problem-oriented medical record
D) The patient database

Question 15

The patient has been in the hospital for a hip replacement.According to his critical pathway,he should have his Foley catheter discontinued on the fourth day after surgery.Instead,the patient has it removed on the third day and is voiding normally with no problems.This would be a sign of:

A) A negative variance
B) Positive case management
C) A positive variance
D) Utilization of SBAR

Question 16

"Patient is wheezing and is experiencing some dyspnea on exertion." This is an example of:

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

Question 17

The patient has been transferred to the nursing home from the acute care hospital.A report was called from the hospital and was received by the RN in charge of the nursing home unit.Upon arrival,the patient is assessed using:

A) The Long-Term Care Facility Resident Assessment Instrument
B) The case management model
C) Collaborative pathways
D) The charting by exception model

Question 18

Which of the following is the best example of objective charting?

A) "The patient states that he has been having severe chest discomfort."
B) "The patient is lying in bed and seems to be in considerable pain."
C) "The patient appears to be pale and diaphoretic and complains of nausea."
D) "The patient's skin is ashen and respiratory rate is 32 and labored."

Question 19

The physician has just visited the patient and is about to leave.The nurse informs the doctor that the patient has been complaining of intermittent but severe headaches and would like something for the pain.As the doctor is leaving the unit,he tells the nurse to give the patient acetaminophen 650 mg PO as needed,and to call him if it doesn't work.The doctor then leaves.The nurse should:

A) Give the medication, but time the order for when the medication is first given because it was not needed until then
B) Not give the medication until the physician returns to write the order
C) Document the order as a verbal, and document the time the order was given
D) Report to the next shift that the patient is having headaches so that staff can call the doctor and get the telephone order

Question 20

Patients on the unit have their vital signs taken routinely at 0800,1200,1600,and 2000.At 1000,a patient complains of feeling "light headed." The nurse takes the patient's vital signs and finds blood pressure to be lower than usual.Within 15 minutes,the patient says that he feels better.The nurse rechecks the blood pressure and finds that it is now back to normal.The nurse should:

A) Document the 1000 vital signs in the graphic record only
B) Not report the incident since it was a transient episode
C) Document the vital signs in the graphic and progress record
D) Document the vital signs as 12 o'clock signs

Question 21

When making written entries in the patient's medical record,describe the nursing care provided and the ____________.

Question 22

More than ________ % of sentinel events are caused by communication problems.

Question 23

To limit liability,nursing documentation must clearly indicate that the nurse provided individualized,goal-directed nursing care to a patient based on the _____________________.

Question 24

The student is caring for a patient on the medical unit and would like to use the patient situation as a case study paper to meet one of the objectives of her course.She asks if she can take copies of the lab reports to use in her paper.The charge nurse allows her to do so but tells her to remove all identifiers from the documents to protect the patient's confidentiality.Besides the patient's name,this would include: (Select all that apply.)

A) Room number
B) Date of birth
C) Medical record number
D) Other identifiable demographics
E) None of above

Question 25

Change-of-shift reports can be given: (Select all that apply.)

A) Face to face
B) Via audiotape
C) In a computer format
D) At each patient's bedside
E) None of above

Question 26

Nursing documentation must have the following characteristics.It must be: (Select all that apply.)

A) Factual
B) Organized
C) Public
D) Complete

Question 27

A mistake is made when the patient's vital signs are recorded on a flow sheet.The nurse should:

A) Scratch out the error and rewrite the notation
B) Use correction fluid and write over the error
C) Discard the sheet and replace the notations on a new sheet
D) Draw a line through the error, write the correct notation above it, and initial the correction

Question 28

The goal of information management is to: (Select all that apply.)

A) Support decision making
B) Improve patient outcomes
C) Ensure patient safety
D) Improve health care documentation
E) None of above

Question 29

Current Joint Commission standards require that ______ patients who are admitted to a health care institution have an assessment of physical,psychosocial,environmental,self-care,patient education,and discharge planning needs.

Question 30

Nursing documentation: (Select all that apply.)

A) Ensures continuity of care
B) Provides legal evidence
C) Evaluates patient outcomes
D) Increases the risk of litigation

Question 31

Discharge planning achieves specific outcomes that include: (Select all that apply.)

A) Identifying patients with ongoing health needs
B) Collaborating with other health care professions
C) Matching the patient with appropriate resources
D) Reflecting the philosophy of the health care organization

Question 32

The American Nurses Association (ANA)guidelines and strategies for safe computer charting recommend: (Select all that apply.)

A) Not sharing passwords
B) Not leaving computer terminals unattended when logged on
C) That software systems have a backup
D) Not leaving information about a patient displayed
E) None of above

Question 33

The purpose of the patient's record is to provide information for: (Choose all that apply.)

A) Education
B) Assessment
C) Financial billing
D) Legal documentation
E) None of above

Question 34

________________ provide a quick,easy reference for health care team members in assessing the patient's status.

Question 35

A student nurse notes that space is left after an entry on the patient's narrative note.The student should:

A) Draw a line through to the end and sign it off
B) Start the next timed notation in that space
C) Fill the line in with additional information
D) Leave the space for other nurses to continue documentation

Question 36

The patient is on a medical unit.Any changes in the patient's condition can be compared with data found on the _______________.

Question 37

A patient's private health information is legally protected by the ________________.

Question 38

________________ measurements for patients on a unit serve as a guide for determining staffing needs.

Question 39

__________________ documentation should include your observations of patient behavior.

Question 40

The abbreviation for every day (___ )is no longer used.

Question 41

___________________ begins at admission and becomes a more prominent part of care as the patient gets closer to discharge.

Question 42

Standardized Care Plans are effective ways to plan care for the patient.To be most effective,however,the SCP must be _________________.

Question 43

The traditional method for recording nursing care and activities,which uses a story-like format usually in chronological order,is known as ______________.

Question 44

The federally mandated ________________________ provides standardized protocols for assessment and care planning and promotes quality improvement within and among facilities.

Question 45

___________________ provide a format for documenting a record of a patient's health status and progress.

Question 46

Multidisciplinary care plans that include key interventions and expected outcomes within an established time frame are known as _______________.

Question 47

An ________________ is any event not consistent with the routine operation of a health care unit or with the routine care of a patient.