Health Assessment
1. Your patient suffers an adverse event and you are now beginning to document.
What information should you enter in the EMR? - correct-answers-Document
relevant clinical facts related to the adverse event in the medical record; for
example, your assessment of the patient's condition, prescribed treatment,
nursing and medical interventions, and the patient's response.
2. Never document in the medical record that an event report was filled out, and
never document the alleged cause of the event. This is better documented on the
event report.
3. What should be documented in an event report? - correct-answers-document the
findings of the investigation: what happened, why it happened, what harm was
done, what responses were made, and what changes are required to prevent a
similar event in the future.
4. Who receives the information from an event report and what use does it serve? -
correct-answers-Event reports generally go to risk manage- ment for use in
determining any policy changes required to eliminate future risk and in education
to avoid similar errors.
5. What are some "red flags" of documentation? - correct-answers--notes that are
sloppy, incomplete, inconsistent, illegible, or have gaps. These re-
flect poorly on the nurse and undermine the nurse's credibility in front of a jury.
• entries that aren't timed or dated or that appear out of sequence
• entries that indicate delays or failures in initiating treatment orders
• entries that show the care provided was substandard or inappropriate
• entries that show care rendered that wasn't supported by a healthcare
provider's
prescription
• unexplained late entries
• erased or obliterated entries
, • lack of documentation of patient education or discharge instructions
• entries made with different ink or pen (if the record is handwritten)
• the statement "Completed an Event Report," which can serve as a red flag
that
6. something went wrong during the patient's care.
7. What are the four (4) elements of a professional negligence case that the plaintiff
must prove? - correct-answers-1) a duty to the patient existed
2) a breach of duty occurred
3) The patient was injured
4) The injury was directly caused by the breach of a standard of care
8. How does the plaintiff prove that a breach of duty occurred? - correct-answers-In
a professional negligence case, the plaintiff must prove that care provided by a
nurse was substandard by calling upon a nursing ex- pert witness (or, in some
states, a physician expert) to establish the appropriate level of care.
9. What are some key documentation pit falls to avoid? - correct-answers--Be
objective (use direct patient quotations in documentation)
-Document at the same time you make your assessment/treatment
-Avoid gaps in the medical record
-Follow your facility's documentation policies
-Document adverse events properly
10. You are making a hand written entry into your patient's medical medical record
but have made an error. Is it acceptable to use white out or erase your mistake? -
correct-answers-No, it is never acceptable to white out, erase or otherwise
obliterate a part of the medical record.
Use one line to cross out your error. Time, Date and initial/sign the correction
with your credentials.
11. A patient calls the unit shortly after being discharged complaining of worsening
headaches after her C2 nerve block procedure. What important nursing action
should the nurse take and then properly document regarding this
communication? - correct-answers-It is very important to document
conversations with patients shortly after discharge. Communicating these
1. Your patient suffers an adverse event and you are now beginning to document.
What information should you enter in the EMR? - correct-answers-Document
relevant clinical facts related to the adverse event in the medical record; for
example, your assessment of the patient's condition, prescribed treatment,
nursing and medical interventions, and the patient's response.
2. Never document in the medical record that an event report was filled out, and
never document the alleged cause of the event. This is better documented on the
event report.
3. What should be documented in an event report? - correct-answers-document the
findings of the investigation: what happened, why it happened, what harm was
done, what responses were made, and what changes are required to prevent a
similar event in the future.
4. Who receives the information from an event report and what use does it serve? -
correct-answers-Event reports generally go to risk manage- ment for use in
determining any policy changes required to eliminate future risk and in education
to avoid similar errors.
5. What are some "red flags" of documentation? - correct-answers--notes that are
sloppy, incomplete, inconsistent, illegible, or have gaps. These re-
flect poorly on the nurse and undermine the nurse's credibility in front of a jury.
• entries that aren't timed or dated or that appear out of sequence
• entries that indicate delays or failures in initiating treatment orders
• entries that show the care provided was substandard or inappropriate
• entries that show care rendered that wasn't supported by a healthcare
provider's
prescription
• unexplained late entries
• erased or obliterated entries
, • lack of documentation of patient education or discharge instructions
• entries made with different ink or pen (if the record is handwritten)
• the statement "Completed an Event Report," which can serve as a red flag
that
6. something went wrong during the patient's care.
7. What are the four (4) elements of a professional negligence case that the plaintiff
must prove? - correct-answers-1) a duty to the patient existed
2) a breach of duty occurred
3) The patient was injured
4) The injury was directly caused by the breach of a standard of care
8. How does the plaintiff prove that a breach of duty occurred? - correct-answers-In
a professional negligence case, the plaintiff must prove that care provided by a
nurse was substandard by calling upon a nursing ex- pert witness (or, in some
states, a physician expert) to establish the appropriate level of care.
9. What are some key documentation pit falls to avoid? - correct-answers--Be
objective (use direct patient quotations in documentation)
-Document at the same time you make your assessment/treatment
-Avoid gaps in the medical record
-Follow your facility's documentation policies
-Document adverse events properly
10. You are making a hand written entry into your patient's medical medical record
but have made an error. Is it acceptable to use white out or erase your mistake? -
correct-answers-No, it is never acceptable to white out, erase or otherwise
obliterate a part of the medical record.
Use one line to cross out your error. Time, Date and initial/sign the correction
with your credentials.
11. A patient calls the unit shortly after being discharged complaining of worsening
headaches after her C2 nerve block procedure. What important nursing action
should the nurse take and then properly document regarding this
communication? - correct-answers-It is very important to document
conversations with patients shortly after discharge. Communicating these
