Chapter 26 Informatics and Documentation-Fundamentals of Nursing

Chapter 26: Informatics and Documentation
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MULTIPLE CHOICE ra



1. A nursing attendant preceptor is working with a student nursing attendant . Which behavi
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or by the student nursing attendant will require the nursing attendant preceptor to interve
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ne?
a. Reading the hospital client ’s plan of care ra ra ra ra ra ra ra




b. Reviewing the hospital client ’s medical record ra ra ra ra ra ra




c. Sharing hospital client information with another student ra ra ra ra ra ra




d. Documenting medication administered to the hospital client ra ra ra ra ra ra




ACCURATE ANSWER:-C ra



When you are a student in a clinical setting, confidentiality and compliance with the Health I
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nsurance Portability and Accountability Act (HIPAA) are part of professional practice. When a
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student nursing attendant shares hospital client information with a friend, confidentiality a
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nd HIPAA standards have been violated, causing the preceptor to intervene. You can review y
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our hospital client s’ medical records only to seek information needed to provide safe and effe
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ctive hospital client care. For example, when you are assigned to care for a hospital client
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, you need to review the hospital client ’s medical record and plan of care. You do not share th
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is information with classmates and you do not access the medical records of other hospital cli
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ent s on the unit. ra ra ra ra




DIF:Analyze (analysis) ra



OBJ:Identify ways to maintain confidentiality of health care record data. ra ra ra ra ra ra ra ra ra ar



TOP:Evaluation MSC: Management of Care ra ra ra




2. A nursing attendant exchanges information with the oncoming nursing attendant about
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a hospital client ’s care. Which action did the nursing attendant complete?
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A verbal reportra ra




b. An electronic record entry ra ra ra




c. A referral ra




d. An acuity rating ra ra




ACCURATE ANSWER:-A ra



Whether the transfer of hospital client information occurs through verbal reports, electronic or
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written documents, you need to follow some basic principles. Reports are exchanges of infor
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mation among nursing attendant s. A hospital client ’s electronic medical record or chart is a c
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onfidential, permanent legal documentation of information relevant to a hospital client ’s healt
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h care. Nursing attendant s document referrals (arrangements for the services of another care
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provider). Nursing attendant s use acuity ratings to determine the hours of care and number o
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f staff required for a given group of hospital client s every shift or every 24 hours.
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DIF:Understand (comprehension) ra



OBJ:Outline the different methods used in record keeping. ra ra ra ra ra ra ra



TOP:Communication and Documentation ra ra MSC: Management of Care ra ra ra




3. A nursing attendant is auditing and monitoring hospital client s’ health records. Which action i
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s the nursing attendant taking?
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, a. Determining the degree to which standards of care are met by reviewing hospital ra ra ra ra ra ra ra ra ra ra ra ra ar



client s’ health records ra ra ra




b. Realizing that care not documented in hospital client s’ health records still ra ra ra ra ra ra ra ra ra ra ra ar



qualifies as care provided ra ra ra




c. Basing reimbursement upon the diagnosisrelated groups documented in hospital client s’ rec
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ords
d. Comparing data in hospital client s’ records to determine whether a new ra ra ra ra ra ra ra ra ra ra ra ar



treatment had better outcomes than the standard treatment ra ra ra ra ra ra ra




ACCURATE ANSWER:-A ra



The auditing and monitoring of hospital client s’ health records involve nursing attendant s
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periodically auditing records to determine the degree to which standards of care are met and
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identifying areas needing improvement and staff development. The mistakes in documentat
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ion that commonly result in malpractice include failing to record nursing actions; this is the a
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spect of legal documentation. The financial billing or reimbursement purpose involves diagn
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osisrelated groups (DRGs) as the basis for establishing reimbursement for hospital client care. F
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or research purposes, the researcher compares the hospital client ’s recorded findings to dete
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rmine whether the new method was more effective than the standard protocol. Data analysi
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s contributes to evidence-based nursing practice and quality health care.
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DIF:Understand (comprehension) ra



OBJ:Identify purposes of a health care record. TO ra ra ra ra ra ra ra



P:Communication and Documentation ra ra MSC: Management of Care ra ra ra




4. After providing care, a nursing attendant charts in the hospital client ’s record. Which
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entry will the nursing attendant document?
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a. Appears restless when sitting in the chair. ra ra ra ra ra ra




b. Drank adequate amounts of water. ra ra ra ra




c. Apparently is asleep with eyes closed. ra ra ra ra ra




d. Skin pale and cool. ra ra ra




ACCURATE ANSWER:-D ra



A factual record contains descriptive, objective information about what a nursing attendant o
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bserves, hears, palpates, and smells. Objective data is obtained through direct observation an
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d measurement (skin pale and cool). For example, ―B/P 80/50, hospital client
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diaphoretic, he ar




art rate 102 and regular.‖ Avoid vague terms such as appears, seems, or apparently because these
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w
ords suggest that you are stating an opinion, do not accurately communicate facts, and do not
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a


inform another nursing attendant of details regarding behaviors exhibited by the hospital clie
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nt . Use of exact measurements establishes accuracy. For example, a description such as ―Int
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a ke, 360 mL of water‖ is more accurate than ―Hospital client ra ra ra ra ra ra ra ra ra ra ra




drank an adequate amount of flui d.‖ ra ra ar ra ra




DIF:Apply (application) ra



OBJ:Explain the guidelines for quality documentation. ra ra ra ra ra ar



TOP:Communication and Documentation MSC: Management of Care ra ra ra ra ra




5. A nursing attendant has provided care to a hospital client . Which entry should the nursin
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g attendant document in the hospital client ’s record? a. Status unchanged, doing well.
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b. Hospital client seems to be in pain and states, ―I feel uncomfortable.‖ ra ra ra ra ra ar ra ra ra ra ar




c. Left knee incision 1 inch in length without redness, drainage, or edema.
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, d. Hospital client is hard to care for and refuses all treatments and medications ra ra ra ra ra ra ra ra ra ra ra ra



. Family is present.
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ACCURATE ANSWER:-C ra



Use of exact measurements establishes accuracy. Charting that an abdominal wound is
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―approximated, 5 cm in length without redness, drainage, or edema,‖ is more descriptive than ra ra ra ra ra ra ra ra ra ra ra ra ra




―large abdominal incision healing well.‖ Include objective data to support subjective data, so yo
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ur charting is as descriptive as possible. Avoid using generalized, empty phrases such as
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―status unchanged‖ or ―had good day.‖ It is essential to avoid the use of unnecessary words an
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d irrelevant details or personal opinions. ―Hospital client is hard to care for‖ is a personal opini
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on and should be avoided. It is also a critical comment that can be used as evidence for nonprof
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essional behavior or poor quality of care. Just chart, ―refuses all treatments and medications.
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‖

DIF:Apply (application) ra



OBJ:Explain the guidelines for quality documentation. ra ra ra ra ra ar



TOP:Communication and Documentation MSC: Basic Care and Comfort ra ra ra ra ra ra




6. Which action by a novice nursing attendant will cause the preceptor to provide follow u
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p instructions?
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a. Documents descriptively. ra




b. Charts consecutively on every other line. ra ra ra ra ra




c. Ends each entry with signature and title. ra ra ra ra ra ra




d. Uses quotations to note hospital client s’ exact words.
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ACCURATE ANSWER:-B ra



Chart consecutively, line by line (not every other line); every other line is incorrect and must b
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e corrected by the preceptor. If space is left, draw a line horizontally through it, and place you
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r signature and credentials at the end. Every other line should not be left blank. All the other
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behaviors are correct and need no followup. Documenting should be as descriptive as possible. E
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nd each entry with signature and title/
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credentials. When recording subjective data, document a hospital client ’s exact words within
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quotation marks whenever possible.
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DIF:Analyze (analysis) ra



OBJ:Discuss legal guidelines for documentation. ra ra ra ra ra



TOP:Communication and Documentation ra ra MSC: Management of Care ra ra ra




7. Which action can the nursing attendant take legally when charting on a hospital cli
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ent ’s record? a. Charts in a legible manner.
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b. States the hospital client is belligerent. ra ra ra ra ra




c. Writes entry for another nursing attendant . ra ra ra ra ra ra




d. Uses correction fluid to correct error. ra ra ra ra ra




ACCURATE ANSWER:-A ra



Record all entries legibly. Do not write personal opinions (belligerent). Enter only objective a
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nd factual observations of hospital client ’s behavior; quote all hospital client comments. Do no
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t erase, apply correction fluid, or scratch out errors made while recording. Chart only for your
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self.

DIF:Understand (comprehension) ra



OBJ:Discuss legal guidelines for documentation. ra ra ra ra ra



TOP:Communication and Documentation MSC: Management of Care ra ra ra ra ra