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Documenting Nursing Activities (Record System Used in an Agency)

- Admission Nursing Assessment: Referred to as the initial database, nursing history, completed when the client is admitted to the nursing unit. It includes the nursing diagnosis, client goals, and outcomes.

- Kardexes: A widely used concise method of organizing and recording data about a client, making information quickly accessible to all health professionals.

Flow Sheets, Progress Notes, and Nursing Discharge/Referral Summaries are also used for documenting nursing activities.

General Guidelines for Recording

1. Date and time must be specific.

2. Timing should be done after providing care.

3. Legibility is important to prevent errors.

4. Use accepted terminology and abbreviations.

5. Correct spelling is essential.

6. Signatures should include the nurse's name and credentials.

7. Accuracy is crucial, including the correct client name and identification.

Reporting

- Change of shift reports: Handoff communication given to the nurse on the next shift to provide continuity of care.

- Telephone reports: Nurses must be concise and accurate when reporting results from radiologists or taking telephone orders.

- Care plan conference: A meeting of a group of nurses to discuss possible solutions to certain client problems.

- Nursing rounds: Procedures in which two or more nurses visit selected clients at each client's bedside to gather information for the plan of care, discuss care, and evaluate care given.

Documentation of Clients' Care

1. Long-Term Care Documentation: Based on professional standards and policies of the healthcare agency, for adults with chronic conditions such as pneumonia or heart disease.

2. Home Care Documentation: Must standardize their documentation methods. Two types of records are used: home health certification and a plan of treatment form, as well as medical update and client information forms.

Questions on Documenting Nursing Activities (Record System Used in an Agency)

Correct Answer is A

Explanation

<p>The client&rsquo;s family contacts, insurance information, and advance directives are part of the administrative data collection, which is not directly related to the client&rsquo;s health status or nursing care.</p>

Correct Answer is ["A","B"]

Explanation

<p>Care plan conferences are not records, but meetings where health professionals discuss the client&rsquo;s needs, goals and progress.</p>

Correct Answer is B

Explanation

<p>it is too vague and incomplete for handoff communication.</p> <p>It does not provide any details about the patient&rsquo;s current status, vital signs, medications, interventions, or goals.</p> <p>It also does not indicate any anticipated changes or potential complications that the next nurse should be aware of.</p>

Correct Answer is D

Explanation

<p>This is the best way to verify a telephone order from a radiologist, as it ensures that the nurse has accurately transcribed the order and that the radiologist has confirmed it.</p> <p>Reading back the order also allows the nurse to clarify any doubts or questions about the order, such as the urgency, the reason, or the patient&rsquo;s condition.</p>

Correct Answer is D

Explanation

No explanation

Correct Answer is C

Explanation

<p>It is not the first action that the nurse should take.</p> <p>The nurse should notify the physician and the charge nurse after assessing the client and documenting the findings.</p>

Correct Answer is D

Explanation

<p>Narrative charting.This type of documentation is an example of narrative charting because it chronicles all of the patient&rsquo;s assessment findings and nursing activities that occurred throughout the shift in a descriptive format.</p>

Correct Answer is ["A","B","D"]

Explanation

<p>Correcting errors by drawing a single line through them is a method used for paper records, not electronic records.Electronic records should have a mechanism to track changes and corrections without altering the original data.</p>

Correct Answer is ["A","B","C"]

Explanation

<p>Documentation should reflect the nursing process and the standards of care, but this is not a complete statement.Documentation should also reflect the patient&rsquo;s perspective, preferences, and goals.Documentation should be patient-centered, holistic, and individualized.</p>

Correct Answer is B

Explanation

<p>it is not true that a computerized system protects client information from unauthorized disclosure or alteration.</p>

Correct Answer is D

Explanation

<p>A statement of facts, changes, trends, and responses to treatment.This is the best way to report a change in a client&rsquo;s condition to another health care provider because it provides clear, concise, and relevant information that can help with decision making and continuity of care.</p>

Correct Answer is A

Explanation

<p>Source, Opinion, Accuracy, Purposeis not a documentation method, but a criteria for evaluating information sources.</p>

Correct Answer is B

Explanation

<p>Documenting personal opinions about the client&rsquo;s condition and care can be considered unprofessional, biased, and disrespectful.It can also damage the nurse-client relationship and expose the nurse to legal liability.</p>

Correct Answer is B

Explanation

<p>Documenting personal opinions about the client&rsquo;s condition and care can be considered unprofessional, biased, and disrespectful.It can also damage the nurse-client relationship and expose the nurse to legal liability.</p>

<p>This is also a correct action to ensure confidentiality and security of EHRs.</p> <p>Reporting any breaches or attempted breaches to the appropriate authority helps to identify and mitigate the impact of any data loss, corruption, or disclosure.It also helps to comply with the legal and regula

<p>Assessment is not the term used to begin each entry, but rather the phase of the nursing process that involves collecting data.</p>

<p>it is not an advantage of using an EHR system.It is a requirement of any health record system, whether electronic or paper-based, to comply with the ethical and legal standards of confidentiality.</p> <p>An EHR system does not provide any additional safeguards that are not already present in a

<p>the nurse should not discuss possible solutions to prevent future errors.</p> <p>This could be premature, unrealistic or inappropriate.</p> <p>The nurse should leave this task to the investigation team or the risk management department, who will analyse the incident and make recommendations

<p>intake and output are important data that indicate the patient&rsquo;s fluid balance and renal function.</p>

<p>focus charting does not provide a chronological record of events, but rather organizes the data by the focus.A chronological record of events can be found in other forms of documentation, such as narrative or SOAP notes.</p>

<p>Applied moist heat compresses to the wound site is an intervention, not an assessment.Interventions are also documented in the plan section of SOAP documentation.</p>

<p>A client teaching record is a document that records the education that has been provided to a patient or family, such as disease process, medications, diet, exercise, self-care, and discharge planning.</p> <p>A client teaching record does not include information about medication administration

<p>a critical pathway does not evaluate the quality and cost-effectiveness of care delivered to clients, but rather aims to promote organised and efficient patient care based on evidence-based medicine.</p>

<p>deleting any information that is incorrect or outdated from the system may compromise theintegrity and availabilityof the client&rsquo;s information.The nurse should follow the established policies and procedures for correcting or updating electronic health records, which may include adding an ad

<p>Home care progress noteis a form that HHAs use to document the patient&rsquo;s progress toward the goals of care, any changes in the plan of care, and any communication with other health care providers.</p> <p>A home care progress note does not certify eligibility or plan treatment.</p>

<p>a discharge planning and referral summary is not a flow sheet.</p>

<p>The nurse should use the following abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min:.</p> <p>&bull; O2: This stands for oxygen and indicates the type of gas being delivered to the patient.</p> <p>&bull; NC: Th
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