Chapter 26: Documentation and Informatics
Chapter 26: Documentation and Informatics
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE
... [Show More] CHOICE
1. A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the
nurse preceptor to intervene?
a. The student nurse reads the patient’s plan of care.
b. The student nurse reviews the patient’s medical record.
c. The student nurse shares patient information with a friend.
d. The student nurse documents medication administered to the patient.
ANS: C
When you are a student in a clinical setting, conৠdentiality and compliance with the Health Insurance
Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares
patient information with a friend, conৠdentiality and HIPAA standards have been violated, causing the
preceptor to intervene. You can review your patients’ medical records only to seek information needed to
provide safe and eৠective patient care. For example, when you are assigned to care for a patient, you need to
review the patient’s medical record and plan of care. You do not share this information with classmates and you
do not access the medical records of other patients on the unit.
DIF:Apply (application)REF:360
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OBJ: Identify ways to maintain conৠdentiality of electronic and written records.
TOP:EvaluationMSC:Management of Care
2. A nurse exchanges information with the oncoming nurse about a patient’s care. Which action did the nurse
complete?
a. A verbal report
b. An electronic record entry
c. A referral
d. An acuity rating
ANS: A
Whether the transfer of patient information occurs through verbal reports, electronic or written documents,
you need to follow some basic principles. Reports are exchanges of information among caregivers. A patient’s
electronic medical record or chart is a conৠdential, permanent legal documentation of information relevant to
a patient’s health care. Nurses document referrals (arrangements for the services of another care provider).
Nurses use acuity ratings to determine the hours of care and number of staৠ required for a given group of
patients every shift or every 24 hours.
DIF:Apply (application)REF:359
OBJ escribe the diৠerent methods used in record keeping.
TOP: Communication and Documentation MSC: Management of Care
3. A nurse is auditing and monitoring patients’ health records. Which action is the nurse taking?
a. Determining the degree to which standards of care are met by reviewing patients’ health records
b. Realizing that care not documented in patients’ health records still qualiৠes as care provided
c. Basing reimbursement upon the diagnosis-related groups documented in patients’ records
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d. Comparing data in patients’ records to determine whether a new treatment had better outcomes than the standard
treatment
ANS: A
The auditing and monitoring of patients’ health records involve nurses periodically auditing records to
determine the degree to which standards of care are met and identifying areas needing improvement and staৠ
development. The mistakes in documentation that commonly result in malpractice include failing to record
nursing actions; this is the aspect of legal documentation. The ৠnancial billing or reimbursement purpose
involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For
research purposes, the researcher compares the patient’s recorded ৠndings to determine whether the new
method was more eৠective than the standard protocol. Data analysis contributes to evidence-based nursing
practice and quality health care.
DIF:Analyze (analysis)REF:357
OBJ:Identify purposes of a health care record.
TOP: Communication and Documentation MSC: Management of Care
4. After providing care, a nurse charts in the patient’s record. Which entry will the nurse document?
a. Appears restless when sitting in the chair
b. Drank adequate amounts of water
c. Apparently is asleep with eyes closed
d. Skin pale and cool
ANS: D
A factual record contains descriptive, objective information about what a nurse observes, hears, palpates, and
smells. Objective data is obtained through direct observation and measurement (skin pale and cool). For
example, “B/P 80/50, patient diaphoretic, heart rate 102 and regular.” Avoid vague terms such as appears,
seems, or apparently because these words suggest that you are stating an opinion, do not accurately
communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the
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patient. Use of exact measurements establishes accuracy. For example, a description such as “Intake, 360 mL of
water” is more accurate than “Patient drank an adequate amount of ৠuid.”
DIF:Apply (application)REF:358 | 361
OBJ escribe ৠve quality guidelines for documentation.
TOP: Communication and Documentation MSC: Management of Care
5. A nurse has provided care to a patient. Which entry should the nurse document in the patient’s record?
a. Status unchanged, doing well
b. Patient seems to be in pain and states, “I feel uncomfortable.”
c. Left knee incision 1 inch in length without redness, drainage, or edema
d. Patient is hard to care for and refuses all treatments and medications. Family is present.
ANS: C
Use of exact measurements establishes accuracy. Charting that an abdominal wound is “approximated, 5 cm in
length without redness, drainage, or edema,” is more descriptive than “large abdominal incision healing well.”
Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using
generalized, empty phrases such as “status unchanged” or “had good day.” It is essential to avoid the use of
unnecessary words and irrelevant details or personal opinions. “Patient is hard to care for” is a personal
opinion and should be avoided. It is also a critical comment that can be used as evidence for nonprofessional
behavior or poor quality of care. Just chart, “Refuses all treatments and medications.”
DIF:Apply (application)REF:358 | 361
OBJ escribe ৠve quality guidelines for documentation.
TOP: Communication and Documentation MSC: Basic Care and Comfort
6. A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to
follow up?
a. The new nurse documents only for self.
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b. The new nurse charts consecutively on every other line.
c. The new nurse ends each entry with signature and title.
d. The new nurse keeps the password secure.
ANS: B
Chart consecutively, line by line (not every other line); every other line is incorrect and must be corrected by the
preceptor. If space is left, draw a line horizontally through it, and place your signature and credentials at the
end. Every other line should not be left blank. All the other behaviors are correct and need no follow-up.
Documenting only for yourself is an appropriate behavior. End each entry with signature and title/credentials.
For computer documentation, keep your password to yourself.
DIF:Apply (application)REF:358
OBJ iscuss legal guidelines for documentation.
TOP: Communication and Documentation MSC: Management of Care
7. A nurse is charting on a patient’s record. Which action will the nurse take that is accurate legally? [Show Less]