Chapter 4 Documentation and Informatics

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Chapter 4  Documentation and Informatics

 

 

Complete Chapter Questions And Answers
 

Sample Questions

 

MULTIPLE CHOICE

1. 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. With whom may the nurse communicate regarding this information?
a.
The patient’s parents
b.
The patient’s significant other only
c.
No one in the hospital until the patient says so
d.
The patient’s physician, significant other, and laboratory personnel

ANS: D
All members of the health care team are legally and ethically obligated to keep patient information confidential. Do not discuss the patient’s examinations, observations, conversations, or treatments with other patients or staff not involved in the patient’s care, unless permission is granted by the patient.

DIF: Cognitive Level: Application REF: Text reference: p. 49
OBJ: Describe measures to maintain confidentiality of patient information.
TOP: Confidentiality KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment

2. 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.”

ANS: D
A record or report contains descriptive, objective information about what you see, hear, feel, and smell. An objective description is the result of direct observation and measurement, such as “respiratory rate 20 and unlabored.” Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. The only subjective data included in a record are what the patient actually verbalizes. Write subjective information with quotation marks, using the patient’s exact words whenever possible. For example, you record, “Patient states, ‘my stomach hurts.’” Avoid terms such as appears, seems, and apparently, which are often subject to interpretation. For example, the description “the patient seems to be in pain” does not accurately communicate the facts to another caregiver. The phrase seems is not supported by any objective facts.

DIF: Cognitive Level: Analysis REF: Text reference: p. 50
OBJ: List guidelines for effective communication and reporting.
TOP: Objective Documentation KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity

3. 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.”

ANS: A
The use of exact measurements in documentation establishes accuracy. For example, charting that an abdominal wound is “5 cm in length without redness, edema, or drainage” is more descriptive than “large wound healing well.” It is essential to know the institution’s abbreviation list, and to use only accepted abbreviations, symbols, and measures (e.g., metric), so that all documentation is accurate and is in compliance with standards. For example, the abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word “daily” or “every day” on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). The term “no complaint” may indicate stoicism on the part of the patient. He may have been in excruciating pain but never complained of it. It also creates a question related to the assessment skills of the nurse. It is essential to avoid unnecessary words and irrelevant details. For example, the fact that the patient is watching TV is only necessary to report when this activity is significant to the patient’s status and plan of care.

DIF: Cognitive Level: Evaluation REF: Text reference: pp. 51-52
OBJ: List guidelines for effective communication and reporting.
TOP: Accurate Documentation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

4. 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. How should the nurse handle documentation for this episode?
a.
Document the 1000 vital signs in the graphic record only.
b.
Not report the incident because 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.

ANS: C
When documenting a significant change on a flow sheet, you describe the change, including the patient response to nursing interventions, in the progress notes. For example, if a patient’s blood pressure becomes dangerously low, record the blood pressure in the progress notes, as well as relevant assessment such as pallor and dizziness and any interventions performed to raise the blood pressure. Common issues in malpractice caused by inadequate or incorrect documentation include failing to give a report or giving an incomplete report to an oncoming shift and failing to document the correct time of events.

DIF: Cognitive Level: Application REF: Text reference: pp. 53-54
OBJ: Identify the purpose of the patient record.
TOP: Flow Sheets and Graphic Records KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment

5. 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.

ANS: B
Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. An acuity recording system determines the hours of nursing care and the number of staff required for a nursing unit. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration.

DIF: Cognitive Level: Analysis REF: Text reference: p. 54
OBJ: Identify the purpose of the patient record. TOP: Acuity Records
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment

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