Documentation and Communication in the Healthcare Team

1.

Which of the following statements by the student nurse demonstrates understanding of the appropriate way to document an error in her charting?
A)
“If I make an error, I can draw a red circle around it.”
B)
“If I make an error, I have to rewrite the entire entry.”
C)
“If I make an error, I draw a single line through it and put my initials by it.”
D)
“If I make an error, I place an X through it.”
E)
“If I make an error, I use white-out on it.”
Ans:
C

Feedback:

When an error occurs, draw a single line through the error and place your initials above it.

2.

The nurse is caring for an elderly resident in a long-term care facility. The patient is crying and states, “I don’t want to live anymore. I am a burden on everyone. I don’t feel like doing anything at all. I don’t even want to get up today.” Which of the following should the nurse record in his charting? Select all that apply.
A)
Patient is crying.
B)
Patient states, “I don’t want to live anymore. I am a burden of everyone. I don’t feel like doing anything at all. I don’t even want to get up today.”
C)
Patient seems depressed.
D)
Patient is suicidal.
E)
Patient is in a bad mood.
Ans:
A, B

Feedback:

When documenting observations of patient behavior, the nurse must maintain objectivity by describing the actual behaviors, rather than attempting to interpret the behaviors. For example, the nurse should not describe the patient as depressed or angry.

3.

The patient states, “I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today.” His arms are folded across his chest. His brow is furrowed and he refuses to allow his morning vital sign measurements. Which of the following should be included in the nurse’s charting? Select all that apply.
A)
Seems angry today
B)
Unhappy with his care
C)
Arms are folded across his chest and brow is furrowed
D)
States, “I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today.”
E)
Refuses to allow morning vital sign measurements
Ans:
C, D, E

Feedback:

When documenting observations of patient behavior, the nurse must maintain objectivity by describing the actual behaviors, rather than attempting to interpret the behaviors. In this case, the nurse should chart that a patient is withdrawn and answers questions with one- or two-word answers. The nurse should not describe the patient as depressed or angry.

4.

Which of the following describe best practices for charting? Select all that apply.
A)
Use long narratives to be sure your documentation is understood
B)
Always use complete sentences
C)
Use only approved abbreviations
D)
Always use the patient’s name and words referring to the patient in each entry
E)
Use partial sentences and phrases
Ans:
C, E

Feedback:

Good charting is concise and brief. In narratives, use partial sentences and phrases; drop the patient’s name and terms referring to the patient. Use abbreviations but only those that are commonly accepted and approved by your facility.

5.

Which of the following should the nurse include in his/her charting? Select all that apply.
A)
The nursing assistant reports the patient’s breath smelled of alcohol.
B)
I feel something is going on she is not telling me.
C)
The patient was overheard telling his family about more bleeding than he has reported to his physician.
D)
The incision is oozing a small amount of red blood.
E)
The patient’s pupils are dilated.
Ans:
A, C, D, E

Feedback:

Entries must be accurate. Nurses must chart only observations that they have seen, heard, smelled, or felt. An observation made by another health professional must be clearly identified as such.

6.

The federally initiated goal of computer-based personal records would likely produce which of the following benefits? Select all that apply.
A)
Access to records outside of the patient’s home facility
B)
Increased accuracy of treatment for the patient outside their home facility
C)
Easier access to data for research
D)
Increased incidence of identity theft
E)
Greater accuracy and improved patient care
Ans:
A, B, C, E

Feedback:

A benefit of computer-based records would not be to increase the incidence of identity theft.

7.

The patient record is utilized for many purposes. Which of following might be uses for the patient record?
A)
Education of student nurses
B)
Reimbursement for services
C)
Research
D)
Giving information over the phone when unidentified callers call the hospital unit
E)
Education for medical students
Ans:
A, B, C, E

Feedback:

The patient medical record may be used for education, reimbursement, and research. The record is never used to give information to callers without written authorization from the patient.

8.

The nurse is caring for a patient with uncontrolled hypertension. His blood pressure has remained controlled for the nurse’s shift. At two-hour intervals the blood pressure was checked by the nurse and found to be essentially the same. The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the patient has a stroke. Years later, the patient files a lawsuit blaming the hospital for his stroke. The nurse who was caring for the patient when his blood pressure was stable cannot recall the exact blood pressure she obtained, but remembers it was normal. Will this recollection suffice in court and why?
A)
Yes, the nurse remembers the pressure as normal during her shift and can swear to it during the deposition.
B)
No, but it will relieve the nurse of any wrongdoing.
C)
No, if the blood pressure measurement was not documented, it did not happen.
D)
Yes, the nurse was not on duty when the stroke occurred.
Ans:
C

Feedback:

Legal cases have been argued with the principle that “If it was not documented, it was not done.” For this reason it is important to document normal as well as abnormal findings. Because nurses and other healthcare team members cannot remember specific assessments or interventions involving a patient years after the fact, accurate and complete documentation at the time of care is essential.

9.

Which of the following flow sheets provides the reader with information on an ongoing record of fluid loss?
A)
Vital sign sheet
B)
Intake and output sheet
C)
Critical care flow sheet
D)
Health assessment flow sheet
Ans:
B

Feedback:

The intake and output sheet is used to maintain an ongoing record of all fluid intake and output.

10.

Charting in which the nurse writes a progress note that relates to one health problem is a
A)
PIE note
B)
Flow sheet
C)
Narrative note
D)
SOAP note
Ans:
D

Feedback:

SOAP note is a progress note that relates to only one health problem.

11.

A nurse in a nursing home is writing a note on a resident that addresses the care the resident has received during the day and the resident’s response to care. What type of note does this represent?
A)
PIE note
B)
Flow sheet
C)
Narrative note
D)
SOAP note
Ans:
C

Feedback:

A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, patient activity pattern, and comfort measures provided, along with the patient’s response.

12.

A concise document that provides most of the patient’s nursing and medical information is a(n)
A)
Nursing care plan
B)
Kardex
C)
Past chart
D)
Office record
Ans:
B

Feedback:

The Kardex is a way to ensure continuity of care from one shift to another and from one day to the next.

13.

During a patient’s hospitalization, he has developed shortness of breath, with edema. What action should the nurse take?
A)
Review the nursing care plan
B)
Implement changes in the current interventions
C)
Involve the family in changes
D)
Revise the plan of care
Ans:
D

Feedback:

A plan of care should be generated at admission and revised to reflect changes in the patient’s condition.

14.

A patient’s record can be more accurate if the nurse
A)
Charts at least every 2 hours
B)
Uses point-of-care documentation
C)
Summarizes patient care at the end of the shift
D)
Delegates charting to the nurse assistant
Ans:
B

Feedback:

Point-of-care documentation takes place as care occurs.

15.

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic patient chart is that
A)
No other charting method is necessary.
B)
Access is open to anyone.
C)
Retrieval of information is more efficient.
D)
It is less costly to maintain.
Ans:
C

Feedback:

With the advance of computer technology, many institutions are transforming the patient record to electronic format. Multiple people may access portions of the record from different sites at the same time.

16.

What activity in charting will assist most in the avoidance of errors?
A)
Objectivity
B)
Organization
C)
Legibility
D)
Timeliness
Ans:
D

Feedback:

Documentation in a timely manner can help avoid errors.

17.

The nurse is interviewing a newly admitted patient. Quoting statements made by the patient will help in maintaining
A)
Subjectivity
B)
Objectivity
C)
Organization
D)
Reimbursement
Ans:
A

Feedback:

Directly quoting statements made by the patient can help in maintaining subjectivity.

18.

A new graduate is working at her first job. Which of the following statements is most important for the new nurse to follow?
A)
Use abbreviations approved by the facility.
B)
Document lengthy entries using complete sentences.
C)
Use PIE charting even if it is not the institution’s charting method.
D)
Only document changes in the patient’s status.
Ans:
A

Feedback:

Use abbreviations but only those that are commonly accepted and approved by the facility.

19.

When the nurse recognizes that he has documented one patient’s assessment data on the wrong patient’s medical record, the nurse should
A)
Draw a single line through the error, and initial it
B)
Use a felt tip pen to cover the error
C)
Use white out to cover the error
D)
Replace the record, rewriting the error
Ans:
A

Feedback:

When an error occurs, draw a single line through the error and place your initial above it.

20.

Which of the following principles should guide the nurse’s documentation of entries on the patient’s medical record?
A)
Nurses may not document for another health professional.
B)
Documentation does not include photographs.
C)
Precise measurements are preferred over approximations.
D)
Nurses should not refer to the names of physicians.
Ans:
C

Feedback:

Precise measurements and times must be used whenever possible.

21.

How can the nurse researcher obtain information from a patient record?
A)
Audit discharge records
B)
Interview nursing staff
C)
Examine institutional procedures
D)
Study patient records
Ans:
D

Feedback:

Nursing and healthcare research is often carried out by studying patient records.

22.

Besides being an instrument of continuous patient care, the patient’s medical record also serves as a(an)
A)
Assessment tool
B)
Legal document
C)
Kardex
D)
Incident report
Ans:
B

Feedback:

The patient record serves as a legal document of the patient’s health status and care received.

23.

What organization audits charts regularly?
A)
Joint Commission on Accreditation of Healthcare Organizations
B)
National League for Nursing
C)
American Nurses Association
D)
Sigma Theta Tau International
Ans:
A

Feedback:

The Joint Commission on Accreditation of Healthcare Organizations audits patient records regularly and encourages institutions to set up ongoing quality assurance programs.

24.

A nurse is working as a case manager, and in this role she audits charts. Audits of patient records are performed primarily for quality assurance and
A)
Reimbursement
B)
Staff development
C)
Research
D)
Change of mechanisms
Ans:
A

Feedback:

Audits of patient records serve a dual purpose: quality assurance and reimbursement.

25.

What dual purpose does an audit serve?
A)
Communication and evaluation
B)
Knowledge and quality
C)
Education and confidentiality
D)
Quality assurance and reimbursement
Ans:
D

Feedback:

Audits of patient records serve a dual purpose: quality assurance and reimbursement.

26.

How can a nurse obtain additional information about a patient?
A)
Read the patient’s history and assessment.
B)
Call the patient’s family.
C)
Ask the patient’s sister about the family history.
D)
Review nursing literature.
Ans:
A

Feedback:

Nurses and other team members gather assessment data from the patient record. By reading about the patient’s history and initial assessment and comparing these data with additional subjective and objective information that has been obtained, current health status and progress toward goals can be determined.

27.

The highest standard for maintaining a patient’s condition is
A)
Reporting
B)
Documentation
C)
Confidentiality
D)
Management
Ans:
C

Feedback:

Documentation and reporting of the patient’s condition require adherence to the highest standard of confidentiality.

28.

The sharing of information about a patient is
A)
Communication
B)
Documentation
C)
Reporting
D)
Verification
Ans:
C

Feedback:

Reporting takes place when two or more people share information about patient care, either face to face, or by audiotape, voice mail, or telephone.

29.

What ensures continuity of care?
A)
Reassessment
B)
Critical thinking
C)
Communication
D)
Integration
Ans:
C

Feedback:

Communication ensures continuity of care and provides essential data for revision or continuation of care.