Question 1

A nurse prepared an audiotaped exchange with another nurse of information about a patient.Which action did the nurse complete? The nurse completed a
A) Report.
B) Record.
C) Consultation.
D) Referral.

Accepted Answer

Reports are oral,written,or audiotaped exchanges of information among caregivers.A patient's record or chart is a confidential,permanent legal document consisting of information relevant to his or her health care.Consultations are another form of discussion in which one professional caregiver gives formal advice about the care of a patient to another caregiver.Nurses document referrals (arrangements for the services of another care provider).

Question 2

A nurse is charting on a patient's record.Which action is most accurate legally?
A) Charts legibly
B) States the patient is belligerent
C) Uses correction fluid to correct error
D) Writes entry for another nurse

Accepted Answer

Record all entries legibly.Do not write personal opinions.Enter only objective and factual observations of patient's behavior; quote all patient comments.For example,patient refuses to cough and deep breathe,saying,"I don't care what you say,I will not do it." Do not erase,apply correction fluid,or scratch out errors made while recording.Chart only for yourself.

Question 3

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.

Accepted Answer

A registered nurse makes a telephone report when significant events or changes in a patient's condition have occurred.Telephone orders and verbal orders usually occur at night or during emergencies.Because the time is 1 AM (0100 military time)and the primary care provider is not present,the nurse will need to call the primary care provider for a telephone order.A verbal order (VO)involves the health care provider giving orders to a nurse while they are standing near each other.Just reading an order that is correctly written in the chart does not require a telephone order.

Question 4

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) Demonstrated use of crutches
D) Used crutches with no difficulties

Accepted Answer

A second progress note method is the PIE format.The narrative note includes P-Problem,I-Intervention,and E-Evaluation.The intervention is "Demonstrated use of crutches." "Patient went up and down stairs" and "Used crutches with no difficulties" are examples of the E."Deficient knowledge regarding crutches" is the P.

Question 5

A nurse is giving a hand-off report to the oncoming nurse.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, Lortab.
D) The family is poor and had to go on welfare.

Accepted Answer

Relay to staff significant changes in the way therapies are to be given (e.g.,different position for pain relief,new medication).Don't simply describe results as "good" or "poor." Be specific.Don't use critical comments about patient's or family's behavior,such as "Mrs.Wills is so demanding." Don't engage in idle gossip.

Question 6

A home health nurse is preparing for an initial home visit.Which information should be included in the patient's home care medical record?
A) Nursing process form
B) Step-by-step skills manual
C) A list of possible procedures
D) Reports to third party payers

Accepted Answer

Information in the home care medical record includes patient assessment,referral and intake forms,interprofessional plan of care,a list of medications,and reports to third party payers.An interprofessional plan of care is used rather than a nursing process form.A step-by-step skills manual and a list of possible procedures are not included in the record.

Question 7

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 data to the problem list.
C) Document the variance in the patient's record.
D) Report a positive variance in the next interdisciplinary team meeting.

Accepted Answer

A variance occurs when the activities on the critical pathway are not completed as predicted,or the patient does not meet expected outcomes.An example of a variance is when a patient develops pulmonary complications after surgery,requiring oxygen therapy and monitoring with pulse oximetry.A positive variance occurs when a patient progresses more rapidly than expected (e.g.,use of a Foley catheter may be discontinued a day early).When a nurse is using the problem-oriented medical record,after analyzing data,health care team members identify problems and make a single problem list.A type of narrative format charting is focus charting.It involves the use of DAR notes,which include D-Data (both subjective and objective),A-Action or nursing intervention,and R-Response of the patient (i.e.,evaluation of effectiveness).

Question 8

A patient is being discharged home.Which information should the nurse include?
A) Acuity level
B) Community resources
C) Standardized care plan
D) Kardex

Accepted Answer

Discharge documentation includes medications,diet,community resources,follow-up care,and whom to contact in case of an emergency or for questions.A patient's acuity level,usually determined by a computer program,is based on the type and number of nursing interventions (e.g.,intravenous [IV] therapy,wound care,ambulation assistance)required over a 24-hour period.Acuity level can be used for staffing and billing.Some institutions use standardized care plans to make documentation more efficient.The plans,based on the institution's standards of nursing practice,are preprinted,established guidelines used to care for patients who have similar health problems.In some settings,a Kardex,a portable "flip-over" file or notebook,is kept at the nurses' station.Most Kardex forms have an activity and treatment section and a nursing care plan section,which organize information for quick reference.

Question 9

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

Accepted Answer

A unique feature of an electronic health record (EHR)is its ability to integrate all pertinent patient information into one record,regardless of the number of times a patient enters a health care system.Although the electronic medical record (EMR)contains patient data gathered in a health care setting at a specific time and place and is a part of the EHR,the two terms are frequently used interchangeably.There are no such terms as electronic charting record or electronic problem record.

Question 10

A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart.What is the preceptor's best response?
A) "A hand-off 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 hand-off 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."

Accepted Answer

Properly performed,a hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care.Reimbursement costs and research priorities/opportunities are functions of the medical record.The purpose of the change-of-shift report is not to establish relationships but to ensure patient safety and continuity of care.

Question 11

A nurse preceptor is working with a student nurse.Which behavior 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.

Accepted Answer

When you are a student in a clinical setting,confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA)are part of professional practice.When a student nurse shares patient information with a friend,confidentiality and HIPAA standards have been violated.You can review your patients' medical records only to seek information needed to provide safe and effective patient care.For example,when you are assigned to care for a patient,you need to review the patient's medical record and plan of care.You do not share this information with classmates and you do not access the medical records of other patients on the unit.

Question 12

A nurse developed the following discharge summary sheet.Which critical information should be added?

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

Accepted Answer

List actual time of discharge,mode of transportation,and who accompanied the patient for discharge summary information.In some settings,a Kardex,a portable "flip-over" file or notebook,is kept at the nurses' station.A Kardex is for nurses,not for patients to take upon discharge.A nurse completes a nursing history form when a patient is admitted to a nursing unit,not when the patient is discharged.SOAP notes are not given to patients who are being discharged.SOAP notes are a type of documentation style.

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 1 inch in length without redness, drainage, or edema
D) Patient is hard to care for and refuses all treatments and medications. Family present.

Accepted Answer

Use of exact measurements establishes accuracy.Charting that an abdominal wound is "5 cm in length without redness,drainage,or edema" is more descriptive than "large wound healing well." Include objective data to support subjective data,so your charting is as descriptive as possible.Avoid using generalized,empty phrases such as "status unchanged" or "had a good day." It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions."Patient is hard to care for" is a personal opinion and should be avoided.It is also a critical comment that can be used as evidence for nonprofessional behavior or poor quality of care.Just chart,"Refuses all treatments and medications."

Question 14

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

Accepted Answer

A factual record contains descriptive,objective information about what a nurse sees,hears,feels,and smells.An objective description is the result of direct observation and measurement.For example,"B/P 80/50,patient diaphoretic,heart rate 102 and regular." Avoid vague terms such as appears,seems,or apparently because these words suggest that you are stating an opinion,do not accurately communicate facts,and do not inform another caregiver of details regarding behaviors exhibited by the patient.Use of exact measurements establishes accuracy.For example,a description such as "Intake,360 mL of water" is more accurate than "Patient drank an adequate amount of fluid."

Question 15

A nurse is using the source record and wants to find the daily weights.Where should the nurse look?
A) Database
B) Medical history and examination
C) Progress notes
D) Graphic sheet and flow sheet

Accepted Answer

In a source record,the patient's chart has a separate section for each discipline (e.g.,nursing,medicine,social work,respiratory therapy)in which to record data.Graphic sheets and flow sheets are records of repeated observations and measurements such as vital signs,daily weights,and intake and output.In the problem-oriented medical record,the database section contains all available assessment information pertaining to the patient (e.g.,history and physical examination,the nurse's admission history and ongoing assessment,the dietitian's assessment,laboratory reports,radiologic test results).In the source record,the medical history and examination contain results of the initial examination performed by the physician,including findings,family history,confirmed diagnoses,and medical plan of care.In the source record,the progress notes contain an ongoing record of the patient's progress and response to medical therapy and a review of the disease process; it often is interdisciplinary and includes documentation from health-related disciplines (e.g.,health care providers,physical therapy,social work).

Question 16

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough.When is the best time the nurse should 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

Accepted Answer

Ideally,discharge planning begins at admission.Right before discharge is too late for discharge planning.After the congestion is treated is also too late for discharge planning.Usually the primary care provider writes the order too close to discharge,and nurses do not need an order to begin the teaching that will be needed for discharge.By identifying discharge needs early,nursing and other health care professionals can begin planning for home care,support services,and any equipment needs at home.

Question 17

A preceptor is working with 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.

Accepted Answer

Chart consecutively,line by line (not every other line); if space is left,draw a line horizontally through it,and sign your name at the end.Every other line should not be left blank.Record all entries legibly and in black ink.End each entry with your signature and title.For computer documentation,keep your password to yourself.Using black ink,ending each entry with signature and title,and keeping the password secure are all appropriate behaviors.

Question 18

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

Accepted Answer

Elements in a change-of-shift report include identification of significant changes in measurable terms (e.g.,pain scale)and by observation.Report elements do not include normal findings or routine information retrievable from other sources or derogatory or inappropriate comments about the patient or family,which could possibly lead to legal charges if overheard by the patient or family.This kind of language contributes to prejudicial opinions about the patient.Don't simply describe results as "good" or "poor." Be specific.

Question 19

Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of 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.

Accepted Answer

The patient record is a valuable source of data for all members of the health care team.Its purposes include communication,legal documentation,financial billing,education,research,and auditing/monitoring.The auditing/monitoring purpose involves nurses auditing records throughout the year to determine the degree to which standards of care are met and to identify areas needing improvement and staff development.The legal documentation purpose involves the concept that even though nursing care may have been excellent,in a court of law,"care not documented is care not provided." The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs)as the basis for establishing reimbursement for patient care.For research purposes,the researcher compares the patient's recorded findings to determine whether the new method was more effective than the standard protocol.Analysis of data from research contributes to evidence-based nursing practice and quality health care.

Question 20

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning and for meeting quality improvement within and across facilities.Which task did the nurse just complete?
A) A focused assessment/specific body system
B) The Resident Assessment Instrument/Minimum Data Set
C) An admission assessment and acuity level
D) An intake assessment form and auditing phase

Accepted Answer

You assess each resident in a long-term care agency receiving funding from Medicare and Medicaid programs using the Resident Assessment Instrument/Minimum Data Set (RAI/MDS).This documentation provides standardized protocols for assessment and care planning and a minimum data set to promote quality improvement within and across facilities.A focused assessment is limited to a specific body system.An admission assessment and acuity level is performed in the hospital.An intake assessment is for home health.There is no such thing as an auditing phase.

Quiz 26: Documentation and Informatics

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

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

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

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 nurse is giving a hand-off report to the oncoming nurse.Which information is critical for the nurse to report?

A home health nurse is preparing for an initial home visit.Which information should be included in the patient's home care medical record?

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

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

A nurse preceptor is working with a student nurse.Which behavior by the student nurse will require the nurse preceptor to intervene?

A nurse developed the following discharge summary sheet.Which critical information should be added?

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

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

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

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

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

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?

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

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning and for meeting quality improvement within and across facilities.Which task did the nurse just complete?