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Which of the following statements is accurate concerning the importance of nursing documentation?
Nursing documentation is critical to receiving reimbursement from insurance companies. Explanation:The amount of reimbursement your organization receives depends, in large part, on the appropriateness and accuracy of your documentation. Nursing documentation is a communication tool for all healthcare disciplines. Nursing documentation is frequently used to legally assess the quality and appropriateness of patient care. Failure to document nursing actions may be interpreted as failure to provide adequate and necessary nursing care. Nurse practice acts are reviewed and revised fairly frequently. You must be alert to changes in the nurse practice act in your state and perform your duties accordingly. This includes changes in documentation that reflect changes in nursing practice.
Jenny is a 14-year-old diabetic who has had difficulty controlling her blood glucose level. She has both hyperglycemic and hypoglycemic episodes and usually fails to recognize their signs and symptoms until she becomes dangerously ill. After providing care patient education about the signs and symptoms of both hyper and hypoglycemia, you document your evaluation of Jenny's knowledge. Which of the following is the MOST APPROPRIATE documentation of your evaluation?
Jenny is able to verbalize the signs and symptoms of both hyper and hypoglycemia and what to do if experiencing these signs and symptoms. Explanation:This response clearly states what Jenny is able to do.
All of the following are advantages of narrative documentation
Narrative notes are flexible. Narrative notes allow in-depth description of nursing interventions. Narrative notes are efficiently combined with other documentation tools. Narrative notes make it easy to track problems and outcomes.
Which of the following statements pertaining to narrative documentation is accurate?
Most organizations that adopt the narrative system combine it with other systems. Explanation:Narrative notes are flexible but can become lengthy and repetitious. Combining them with other systems helps to make them more concise and avoid repetition.
Nursing documentation is
- A legal account of how you fulfill your professional responsibilities.
- Explanation:Nursing documentation is a legal account of how professional responsibilities are fulfilled. It offers a nurse legal protection and is used by insurance company and Medicare examiners to determine reimbursement. The federal government does not have a nurse practice act. Nurse practice acts are determined by each state.
Evaluate the following narrative note:
Alert and oriented to person, place, and time. Is cheerful and cooperative. Able to transfer from bed to wheelchair independently. Can't remember to unlock wheelchair brakes. Demonstrated how and why to unlock wheelchair brakes for patient. Patient demonstrated how to unlock brakes prior to moving wheelchair. -------Beth Doyle, RN
Based on your evaluation, which of the following statements is correct?
The terms cheerful and cooperative are opinions. Explanation:Opinion statements are inappropriate. Evaluation of the patient's ability is critical to achieving outcomes. The line drawn before the nurse's signature is appropriate since it prevents the addition of "extra" or inaccurate information by another person. Narrative notes do not require nursing diagnosis statements.
The process of collecting pertinent information about your patient from various sources for the purpose of determining patient needs is:
- Explanation:The first step in the nursing process, assessment, is to collect data in order to determine patient needs and to plan care. Implementation is the process of carrying out nursing interventions. Outcome determination is goal identification. Evaluation is the process of analyzing the effectiveness of the plan of care.
Analyze the following documentation example:
Number 2 Acute Pain
S: Patient states, "I am in a lot of pain."
O: Patient identifies pain as a level 10 on Community Hospital's pain assessment scale.
A: Patient says she is in pain, but her discomfort is probably increased because she is in the midst of a divorce.
P: Administer pain medication per physician's order.
-------------------------------------------------------------------------------------------------Jeff Mason, RN
Based on your analysis, which of the following statements is TRUE?
- The nurse's assessment is judgmental and offers no objective findings to justify her conclusions about the patient's discomfort.
- Explanation:The nurse is making assumptions about the patient's discomfort without objective data to justify such assumptions. The FOCUS format, not SOAP, requires a column for nursing diagnoses. Problems are numbered as they arise, not in order of priority. The SOAP format is an important part of the POMR.
Which of the following violates legal principles of documentation?
- Documenting a patient as belligerent when he punches a security guard.
- Explanation:The word belligerent is an opinion. Describe the patient's actions and document what he says in quotes.
Which of the following appropriately corrects a documentation error?
Correct errors by drawing a single line through the mistaken entry, document why the entry is a mistake, sign, date, and time the explanation about the mistake.
Which of the following examples is documented appropriately according to the FOCUS system?
Choice 3 is an example of correct FOCUS charting. Choice 1 does not correctly state a nursing diagnosis in the focus column. Choice 2 does not contain any evaluation of the effectiveness of the patient/family education. Choice 4 does not have a correctly written nursing diagnosis nor does it contain evaluation of the patient/family education.
David is assigned to care for several seriously ill post-op patients. He doesn't know if he'll be able remember to chart all important aspects of care. So he should:
- Document important aspects of care as soon as possible after they are performed.
- Explanation:David should never leave blank space or ask a colleague to document for him. He must document on all of his patients.
All of the following statements about late entries are true EXCEPT:
- Most organizations prohibit the practice of late entries.
- Explanation:Although late entries can look suspicious, there are times when they are necessary. Follow your organization's policies and procedures for documenting late entries.
The documentation system that eliminates the need to chart routine nursing care, requires the use of interdisciplinary standardized care plans, and is significantly different from traditional charting systems is:
- Explanation:The description is that of Charting by Exception (CBE).
What information is contained in the focus column in the FOCUS documentation system?
- nursing diagnosis
- Explanation:The focus column contains the nursing diagnosis.
Which of the following examples of an unusual event is correct?
- Patient lowered to floor by nurse during transfer from bed to chair after patient stated that she was losing her balance. No apparent injury to patient. Assisted to stand by two nurses. Completed transfer to chair.
- Explanation:Information about the event, nursing interventions, and evaluation are documented. Do not document that an incident report was completed since this gives attorneys legal access to the report if it is mentioned in the medical record. Choice 1 does not provide adequate assessment, intervention, or evaluation information.
Which of the following is an important principle of using an EMR?
- Do not display patient information on a monitor if someone else can see it.
- Explanation:Patient information should not be displayed where others can see it. Always log off from a computer terminal even if you are only going to be gone for a few minutes. Do not share your password with anyone. Lab results should not be printed and shared with large groups of colleagues for no apparent reason
Which charting system mandates that interdisciplinary standardized care plans be developed and used by the entire healthcare team?
- Explanation: CBE or "charting by exception" mandates that organizations that use CBE must have interdisciplinary standardized care plans that address all possible patient problems.
Which of the following documentation entries is legally correct?
- Patient’s husband smells of alcohol. In the presence of a nursing assistant shouts at his wife, “So you had to have another girl! I thought this time you were supposed to give me a son!”
- Explanation:Objective findings were charted and patient’s comments were put in quotes.
Numbers each problem to correspond with how the problems are numbered throughout the POMR Explanation:According to the guidelines for problem-oriented documentation, problems are numbered so that all persons reading the documentation are able to identify the problem under discussion. When a problem is resolved a line is drawn through it and that particular number is not used again in the patient’s medical record.
The documentation system that requires the maintenance of a daily assessment flow sheet is
- Explanation: PIE (Problem-Intervention-Evaluation) requires the maintenance of such a flow sheet, which organizes findings under major categories.
Which of the following is an example of proper documentation?
- Patient found sitting on the floor next to her bed. Alert and oriented, she states, “I was trying to go to the bathroom and fell." Pupils equal and reactive. No difficulty moving extremities. Patient assisted to bed and Dr. Wilson notified.
- Explanation: Only facts are provided and patient’s comments are placed in quotes. Assessment and actions taken are documented. Statements about incident reports should not be included in the medical record.
Evaluate the following documentation: Patient is alert and oriented to person, time, and place. She is being discharged today. Understands how to take her medications. Is able to transfer from bed to wheelchair and wheelchair to bed independently. Remembers to lock brakes on wheelchair before performing transfers.
- Assessment of her ability to take medications is incomplete.
- Explanation:Documenting that a patient “understands” is not measurable. Information about her ability to identify her medications, when to take them, and to identify side effects and what to do about them is needed.
To correct an error when using a handwritten documentation system you should:
Draw one line through the error, your name, the date, and time, and why the correction was necessary. Explanation: By drawing one line through the error it can still be read as well as the explanation for the correction. The correction should be signed and dated to show how and when the correction was made.
Which of the following desired patient outcomes is correctly written for a patient care plan?
- Patient will demonstrate safe and accurate self-catheterization of the bladder.
- Explanation: It states exactly what the patient will do and is a measurable objective.
It is a busy day on the surgical unit. Two nurses have called in sick, making staffing short. Daniel has just finished a sterile dressing change on his patient. As he is about to document his actions and wound assessment on the EMR, he hears a colleague yell for help. Her patient has gone into cardiac arrest. Daniel should:
- Close the EMR, assist with resuscitation efforts, and return as soon as possible to complete his documentation.
- Explanation: Daniel should close the EMR to prevent unauthorized use and patient confidentiality. He should then help to resolve the emergency situation, and then return as soon as possible to complete his documentation.
Which of the following documentation samples adheres to basic legal principles?
Patient states, “I am sick of you stupid people telling me that I should lose weight. You’re all idiots.” Patient then makes a fist with his right hand and attempts to punch nursing assistant with this fist. Security called. Explanation:Documentation is objective. Patient comments are quoted and actions are documented objectively.