Potter & Perry Ch 26 Documentation Review Questions ALL ANSWERS 100% CORRECT LATEST SOLUTION 2022 EDITION AID GRADE A+

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? 1. Avoid rushing when charting an entry 2. Use correction fluid to remove the entry 3. Draw a single line through the statement and initial it 4. Enter only objective and factual information about the patient - 4. Enter only objective and factual information about the patient Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record. A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: 1. Uses SBAR as a format when providing the report 2. Gives a newly ordered medication before entering the order in the patient's medical record 3. Reads the orders back to the health care provider after receiving them and verifies their accuracy 4. Asks the preceptor to listen in on the phone conversation - 2. Gives a newly ordered medication before entering the order in the patient's medical record Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur. As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? 1. The patient has a defiant attitude and is demanding his test results 2. The patient appears to be upset with his nurse because he wants his test results immediately 3. The patient is demanding and complains frequently about his doctor 4. The patient stated that he felt frustrated by the lack of information he received regarding his tests. - 4. The patient stated that he felt frustrated by the lack of information he received regarding his tests. Answer 4 is a nonjudgmental statement regarding the nurse's observations about the patient. Answers 1 and 3 are judgmental, and information in the medical record should be factual and nonjudgmental. Answer 2 needs to be more specific regarding the reason for the patient's concern. You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? 1. HIPAA allows all hospital staff access to your medical record 2. HIPAA limits the information that is documented in your medical record 3. HIPAA provides you with greater control over your personal health care information 4. HIPAA enables health care institutions to release all of your personal information to improve continuity of care - 3. HIPAA provides you with greater control over your personal health care information HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patient's medical record. A patient asks for a copy of her medical record. The best response by the nurse is to: 1. State that only her family may read the record 2. Indicate that she has the right to read her record 3. Tell her that she is not allowed to read her record 4. Explain that only health care workers have access to her record - 2. Indicate that she has the right to read her record Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission.