Question 1

Accurate documentation by the nurse is necessary since proper documentation:

Accepted Answer

Accurate documentation is necessary for hospitals to be reimbursed according to diagnostic-related groups (DRGs). DRGs are a system used to classify hospital admissions. Health care documentation is any written or electronically generated information about a patient that describes the patient, the patient's health, and the care and services provided, including the dates of care. These records may be paper or electronic documents, such as electronic medical records, faxes, e-mails, audiotapes, videotapes, and images.

Question 2

Nursing documentation is guided by:

Accepted Answer

Nursing documentation is guided by the five steps of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. Standardized nursing terminologies such as the North American Nursing Diagnosis Association-International (NANDA-I) nursing diagnoses, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) may be used in the documentation process.

Question 3

How should the nurse correct an error in charting?

Accepted Answer

Documentation mistakes must be acknowledged. If an error is made in paper documentation, a line is drawn through the error and the word error is placed above or after the entry, along with the nurse's initials and followed by the correct entry. Notes should never be altered or obliterated. Documentation mistakes must be acknowledged.

Question 4

The nurse is preparing to administer medications to the patient. Prior to doing so, she/he compares the provider orders with the:

Accepted Answer

A medication administration record (MAR) is a list of ordered medications, along with dosages and times of administration, on which the nurse initials medications given or not given. A paper MAR usually includes a signature section in which the nurse is identified by linking the initials used with a full signature. The EHR includes an electronic medication administration record (eMAR). Flow sheets and checklists may be used to document routine care and observations that are recorded on a regular basis, such as vital signs, and intake and output measurements. Data collected on flow sheets may be converted to a graph, which pictorially reflects patient data. Originally, the Kardex was a non-permanent filing system for nursing records, orders, and patient information that was held centrally on the unit. Although computerization of records may mean that the Kardex system is no longer active, the term kardex continues to be used generically for certain patient information held at the nurses' station. An admission summary includes the patient's history.

Question 5

The nurse is charting using paper nursing notes. The nurse is aware that:

Accepted Answer

The medical record is seen as the most reliable source of information in any legal action related to care. When legal counsel is sought because of a negative outcome of care, the first action taken by an attorney is to acquire a copy of the medical record. Notes should never be altered or obliterated. Documentation mistakes must be acknowledged. If an error is made in paper documentation, a line is drawn through the error and the word error is placed above or after the entry, along with the nurse's initials and followed by the correct entry.

Question 6

The process of making a change-of-shift report (handoff):

Accepted Answer

An ineffective handoff may lead to wrong treatments, wrong medications, or other life-threatening events, increasing the length of stay and causing patient injury or death. The handoff process can be an opportunity for collaborative problem solving. Improvement in the handoff process can increase patient safety and promote positive patient outcomes. During an average hospital stay of approximately 4 days, as many as 24 handoffs can occur for just one patient because shifts change every 8 to 12 hours and many individuals are responsible for care.

Question 7

The patient has fallen when trying to climb out of bed. The nurse:

Accepted Answer

Incident reports are objective, nonjudgmental, factual reports of the occurrence and its consequences. The incident report is not part of a medical record but is considered a risk management or quality-improvement document. The fact that an incident report was completed is not recorded in the patient's medical record; however, the details of a patient incident are documented.

Question 8

The nurse is caring for patients on unit that uses electronic health records (EHRs). In order to protect personal health information, the nurse should:

Accepted Answer

Access to an EHR is controlled through assignment of individual passwords and verification codes that identify people who have the right to enter the record. Passwords and verification codes should never be shared with anyone. Health care information systems have the ability to track who uses the system and which records are accessed. These organizational tools contribute to the protection of personal health information. Disadvantages of use of computers for documentation include computer and software failure and problems if there is a power outage.

Question 9

Paper records are being replaced by other forms of record keeping because:

Accepted Answer

Paper records have several potential problems. Paper is fragile, susceptible to damage, and can degrade over time. It may be difficult to locate a particular chart because it is being used by someone else, it is in a different department, or it is misfiled. Storage and control of paper records can be a major problem.

Question 10

Nursing documentation is an important part of effective communication among nurses and with other health care providers. As such, the nurse:

Accepted Answer

Nursing documentation is an important part of effective communication among nurses and with other health care providers. Documentation should be factual and nonjudgmental, with proper spelling and grammar. Events should be reported in the order they happened, and documentation should occur as soon as possible after assessment, interventions, condition changes, or evaluation. Each entry includes the date, time, and signature with credentials of the person documenting. Double documentation of data should be avoided because legal issues can arise as a result of conflicting data.

Question 11

Which of the following is true regarding nursing documentation?

Accepted Answer

The ANA's model for high-quality nursing documentation reflects the nursing process and includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and retrievability. Standards for documentation are established by each health care organization's policies and procedures. They should be in agreement with The Joint Commission's standards and elements of performance, including having a medical record for each patient that is accessed only by authorized personnel. General principles of medical record documentation from the Centers for Medicare and Medicaid Services (2010) include the need for completeness and legibility; the reasons for each patient encounter, including assessments and diagnosis; and the plan of care, the patient's progress, and any changes in diagnosis and treatment.

Question 12

The use of electronic health records:

Accepted Answer

Adoption of an EHR system produces major cost savings through gains in productivity and error reduction, which ultimately improves patient health status. The most common benefits of electronic records are increased delivery of guideline-based care, better monitoring, reduced medication errors, and decreased use of care. Use of EHRs can reduce storage space, allow simultaneous access by multiple users, facilitate easy duplication for sharing or backup, and increase portability in environments using wireless systems and handheld devices. Although data are often entered by keyboard, they can also be entered by means of dictated voice recordings, light pens, or handwriting and pattern recognition systems.

Question 13

The medical record:

Accepted Answer

The medical record is a clinical data archive. The medical record serves as a tool for biomedical research and provider education, collection of statistical data for government and other agencies, maintenance of compliance with external regulatory bodies, and establishment of policies and regulations for standards of care. The record serves as the major communication tool between staff members and as a single data access point for everyone involved in the patient's care. It is a legal document that must meet guidelines for completeness, accuracy, timeliness, accessibility, and authenticity. The record can be used to assess quality-of-care measures, determine the medical necessity of health care services, support reimbursement claims, and protect health care providers, patients, and others in legal matters.

Question 14

The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. The best central location to obtain this information is the:

Accepted Answer

An admission summary includes the patient's history, a medication reconciliation, and an initial assessment that addresses the patient's problems, including identification of needs pertinent to discharge planning and formulation of a plan of care based on those needs. The discharge summary addresses the patient's hospital course and plans for follow-up, and it documents the patient's status at discharge. It includes information on medication and treatment, discharge placement, patient education, follow-up appointments, and referrals. Flow sheets and checklists may be used to document routine care and observations that are recorded on a regular basis, such as vital signs, medications, and intake and output measurements. Although computerization of records may mean that the Kardex system is no longer active, the term kardex continues to be used generically for certain patient information held at the nurses' station.

Question 15

The nurse is charting using electronic documentation. With electronic documentation:

Accepted Answer

Log-on access to the electronic record identifies the person charting or making a change. If an error is made in electronic documentation, it can be corrected on the screen view but the error and correction process remains in the permanent electronic record. Any correction in documentation that indicates a significant change in patient status should include notification of the primary care provider.

Question 16

PIE, APIE, SOAP, and SOAPIE are:

Accepted Answer

The nurse's notes may be in a narrative format or in a problem-oriented structure such as the PIE, APIE, SOAP, SOAPIE, SOAPIER, DAR, or CBE format. Narrative charting is chronologic, Charting by exception (CBE) is documentation that records only abnormal or significant data.

Question 17

If a verbal or phone order is necessary in an emergency, the order:

Accepted Answer

If a verbal or phone order is necessary in an emergency, the order must be taken by a registered nurse (RN) who repeats the order verbatim to confirm accuracy and then enters the order into the paper or electronic system, documenting it as a verbal or phone order and including the date, time, physician's name, and RN's signature. Most facility policies require the physician to co-sign a verbal or telephone order within a defined time period.

Question 18

A type of charting that records only abnormal or significant data is:

Accepted Answer

Charting by exception (CBE) is documentation that records only abnormal or significant data. A PIE note is used to document problem (P), intervention (I), and evaluation (E). A SOAP note is used to chart the subjective data (S), objective data (O), assessment (A), and plan (P). Narrative charting is chronologic, with a baseline recorded on a shift-by-shift basis. Data are recorded in the progress notes, often without an organizing framework. Narrative charting may stand alone, or it may be complemented by other tools.

Question 19

The nurse is charting in the paper medical record. She should:

Accepted Answer

Entries into paper medical records are traditionally made with black ink to enable copying or scanning, unless a facility requires or allows a different color. The date, time, and signature, with credentials of the person writing the entry, are included in the entry. No blank spaces are left between entries because they could allow someone to add a note out of sequence.

Question 20

The nurse is admitting a patient who has had several previous admissions. In order to obtain a knowledge base about the patient's medical history, the nurse may use the:

Accepted Answer

The EHR is a longitudinal record of health that includes the information from inpatient and outpatient episodes of health care from one or more care settings. The EMR is a record of one episode of care, such as an inpatient stay or an outpatient appointment. CPOE allows clinicians to enter orders in a computer that are sent directly to the appropriate department. It does not provide historical data. The American Recovery and Reinvestment Act of 2009 is the government mandate that requires the use of a certified EHR for each person in the United States by 2014.

Quiz 10: Documentation, Electronic Health Records, and Reporting