This quiz assesses knowledge in nursing documentation, reporting, and informatics. It covers practical scenarios such as medication orders, charting methods, and legal aspects of nursing documentation, aiming to enhance accuracy and legal compliance in nursing practice.
Vulnerability to legal liability since nurse’s safe, routine care is not recorded
Increased workload for nurses in order to complete necessary documentation
Failure to identify and record client problems and associated interventions
OSignificant differences in the charting between nurses due to lack of standardizationption 4
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Narrative notes
SOAP notes
Focus charting
Charting by exception
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“Client complaining of abdominal pain rated at 8/10.”
“Client is guarding her abdomen and occasionally moaning.”
“Client has a history of recent abdominal pain.”
“2 mg Dilaudid PO administered with good effect”
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Testimony of other nurses
Testimony of expert witnesses
Client’s record
Client’s family
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“Client complaining of severe pain.”
“Client appears to be in a lot of pain and is crying.”
“Client states has pain; walking in hall with ease.”
“Client states pain is a 9 on a scale of 1 to 10.”
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“Client is overwhelmed by the diagnosis of pancreatic cancer.”
“Client’s kidneys are producing sufficient amount of measured urine.”
“Following oxygen administration, vital signs returned to baseline.”
“Client complained about the quality of the nursing care provided on previous shift.”
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AJRN
Alice J, RN
A. Jones, RN
Alice Jones
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Writing the client’s name on the student care plan
Providing the instructor with plans for care
Discussing the medications with a unit nurse
Providing information to the physician about laboratory data
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May walk twice a day
May be up as desired
May only go to the bathroom
Must remain on bed rest
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Problem-oriented medical record
Source-oriented record
PIE charting system
Focus charting
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Problem-oriented medical record (POMR)
Source-oriented record
PIE charting system
Focus charting
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Client complaints of pain
Client history
Client’s chief complaint
Client interventions
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Problem-oriented medical record
Charting by exception
PIE charting system
Focus charting
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Date it and put it in the client’s record.
Sign it and put it in the Kardex.
Individualize it to the specific client.
Use it as printed, based on common needs.
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Progress notes
Nursing notes
Critical paths
Graphic record
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PIE system
Minimum data set
OASIS
Charting by exception
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Means of identifying risks
Basis for staff evaluation
Basis for disciplinary action
Format for audiotaped report
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Nursing care conferences
Staff visits
Interdisciplinary referrals
Nursing care rounds
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Data, information, knowledge
Process, documentation, analysis
Research, controls, variables
Hypothesis, nursing, practice
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“I am sorry that you had to suffer this way. The nurse on night duty should be fired.”
“It’s hard to be in bed and ask for help. You ring for a nurse who never seems to help.”
“You seem to be impatient. The nurses work very hard and they do whatever they can.”
“I can see that you are angry. What the nurse did is wrong, and it won’t happen again.”
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Pay courtesy calls to staff members before attending the meeting.
Wait for the physicians to arrive before exchanging notes.
Avoid asking questions related to the medical record.
Come prepared with material required to take notes.
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Erase the incorrect statement and write the correct one.
Cross out the wrong statement in a way that is not readable.
Use correction fluid to obliterate what has been written.
Cross out the incorrect statement with a single line.
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Information is documented in separate forms by each health care personnel.
It is a unified, cooperative approach for resolving the client’s problems
It is organized at one location according to the client’s health problems.
It is compiled to facilitate communication among health care professionals.
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Plan of care
Data, action, and response
Problem selected
Nursing activities during a shift
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Client assessment
Intervention carried out
Written plan of care
Multidisciplinary interventions
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Objectivity
Organization
Legibility
Timeliness
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PIE note
Flow sheet
Narrative note
SOAP note
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U (unit)
QD (daily)
NPO (nothing per os)
ML (milliliters)
> (greater than)
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A nurse working in a physician’s office puts out a sign-in sheet for incoming clients.
Two nurses are overheard talking about a client through the door of an empty client room.
A nurse places a client chart in a holder on the examining room door with the name facing out.
A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms.
A nurse calls out the name of a client who is seated in the waiting room
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A nurse discusses a client with a coworker in the elevator.
A nurse shares her computer password with a relative of a client.
A nurse checks the medical record of a client to see who should be called in an emergency.
A nurse updates the employer of a client regarding the client’s return to work.
A nurse uses a computer to document a client’s response to pain medication.
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For any nurse–client interaction
When admitting a client
When receiving a client post operatively
When assisting a client with ADLs
When a procedure is performed
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Completely erase or delete the erroneous entry if possible
Use a highlighter to mark the incorrect entry and place initials next to it.
Strike out the entry with a single line, place initials next to it, and write the correct entry.
Black out the erroneous entry with a dark pen or marker
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ISBAR
EMAR
SOAP
CBE
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The physician’s assessment and treatment
Results of laboratory and diagnostic studies
Nursing documentation and plan of care
Information from other members of the health care team
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When communicating a client’s change in condition to the client’s physician
When providing a change-of-shift report to a colleague
When documenting the care that was provided to a client whose condition recently deteriorated
When reporting to a client’s family member or significant other
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Quiz Review Timeline (Updated): Mar 21, 2023 +
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