Chapter 06 Documenting and Reporting

Chapter 06 Documenting and Reporting

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)Many hospitals are no longer allowing the use of the letter “Q” as an abbreviation either alone or incombination (such as QID, QW, or QS). What is the primary reason for this action?1)A)It is more accurate to write “every” instead of “Q”.B)Errors are reduced when fewer abbreviations are used in orders and in communicatinginformation.C)Not all nurses know that “Q” means “quaque” in Latin.D)A hospital may not have computerized ordering and physicians’ handwriting is often hard toread.Answer:BExplanation:A)Overuse of abbreviations is a major contributing factor in medicationadministration errors; overuse of abbreviations also reduces clarity incommunication. It is not about accuracy as much as clear communication, althoughcertainly if written communication is not clear, errors are more likely to occur. Anyperson who enters data in a client’s record must write clearly so that theinformation can be read by all others. The Latin meaning of a term has no bearingon this scenario.EvaluationSafe, Effective Care Environment-Safety and Infection ControlAnalysisB)Overuse of abbreviations is a major contributing factor in medicationadministration errors; overuse of abbreviations also reduces clarity incommunication. It is not about accuracy as much as clear communication, althoughcertainly if written communication is not clear, errors are more likely to occur. Anyperson who enters data in a client’s record must write clearly so that theinformation can be read by all others. The Latin meaning of a term has no bearingon this scenario.EvaluationSafe, Effective Care Environment-Safety and Infection ControlAnalysisC)Overuse of abbreviations is a major contributing factor in medicationadministration errors; overuse of abbreviations also reduces clarity incommunication. It is not about accuracy as much as clear communication, althoughcertainly if written communication is not clear, errors are more likely to occur. Anyperson who enters data in a client’s record must write clearly so that theinformation can be read by all others. The Latin meaning of a term has no bearingon this scenario.EvaluationSafe, Effective Care Environment-Safety and Infection ControlAnalysis1
D)Overuse of abbreviations is a major contributing factor in medicationadministration errors; overuse of abbreviations also reduces clarity incommunication. It is not about accuracy as much as clear communication, althoughcertainly if written communication is not clear, errors are more likely to occur. Anyperson who enters data in a client’s record must write clearly so that theinformation can be read by all others. The Latin meaning of a term has no bearingon this scenario.EvaluationSafe, Effective Care Environment-Safety and Infection ControlAnalysis2)A student nurse is documenting client care in a client’s medical record. The client’s wife, who is aphysician on the hospital staff, asks the student for the client’s chart. The most appropriate actionby the student nurse at this time is to:2)A)Refer the physician to the charge nurse.B)Give the chart to the physician and complete the nursing documentation when the chart isavailable.C)Tell the physician that she is not allowed to read the chart unless she is involved in herhusband’s care.D)Ask the client’s wife if her husband has given his permission for the chart to be read.Answer:AExplanation:A)A client’s medical record is confidential information and is to be read only by thosedirectly involved in the client’s care. Regardless of the relationship of the physicianto the client and the physician’s status as a hospital staff member, this informationcannot be legally or ethically shared in this scenario. The charted information canbe shared with the client’s wife only after certain criteria are met, such as writtenclient and attending physician consent (or as indicated by agency policy). Referringthis matter to the nurse in charge of the unit is the only choice given that isacceptable.ImplementationSafe, Effective Care Environment-Coordinated CareAnalysisB)A client’s medical record is confidential information and is to be read only by thosedirectly involved in the client’s care. Regardless of the relationship of the physicianto the client and the physician’s status as a hospital staff member, this informationcannot be legally or ethically shared in this scenario. The charted information canbe shared with the client’s wife only after certain criteria are met, such as writtenclient and attending physician consent (or as indicated by agency policy). Referringthis matter to the nurse in charge of the unit is the only choice given that isacceptable.ImplementationSafe, Effective Care Environment-Coordinated CareAnalysis2
C)A client’s medical record is confidential information and is to be read only by thosedirectly involved in the client’s care. Regardless of the relationship of the physicianto the client and the physician’s status as a hospital staff member, this informationcannot be legally or ethically shared in this scenario. The charted information canbe shared with the client’s wife only after certain criteria are met, such as writtenclient and attending physician consent (or as indicated by agency policy). Referringthis matter to the nurse in charge of the unit is the only choice given that isacceptable.ImplementationSafe, Effective Care Environment-Coordinated CareAnalysisD)A client’s medical record is confidential information and is to be read only by thosedirectly involved in the client’s care. Regardless of the relationship of the physicianto the client and the physician’s status as a hospital staff member, this informationcannot be legally or ethically shared in this scenario. The charted information canbe shared with the client’s wife only after certain criteria are met, such as writtenclient and attending physician consent (or as indicated by agency policy). Referringthis matter to the nurse in charge of the unit is the only choice given that isacceptable.ImplementationSafe, Effective Care Environment-Coordinated CareAnalysis3)A newly licensed nurse has accepted a position with a nursing registry. The nurse will be going toseveral different hospitals and will be required to document according to each particular facility’spolicy. Regardless of the documentation method or system, the nurse knows that the primary focusof client documentation is:3)A)To communicate client status and responses using the nursing process.B)To record nursing actions performed in accordance with medical and nursing diagnoses.C)To prevent legal action should an error be made during a client’s hospital stay.D)To coordinate all members of the healthcare team.Answer:AExplanation:A)A client’s medical record documents the client’s ongoing status, regardless of thesystem or method used. The focus should be on the client, not on the nurse or otherhealthcare providers involved in the client’s care. The use of the nursing process asa guideline in documentation enables nurses to have a common basis from whichto record data and promotes completeness and clarity in communication.AssessmentSafe, Effective Care Environment-Coordinated CareApplicationB)A client’s medical record documents the client’s ongoing status, regardless of thesystem or method used. The focus should be on the client, not on the nurse or otherhealthcare providers involved in the client’s care. The use of the nursing process asa guideline in documentation enables nurses to have a common basis from whichto record data and promotes completeness and clarity in communication.AssessmentSafe, Effective Care Environment-Coordinated CareApplication3
C)A client’s medical record documents the client’s ongoing status, regardless of thesystem or method used. The focus should be on the client, not on the nurse or otherhealthcare providers involved in the client’s care. The use of the nursing process asa guideline in documentation enables nurses to have a common basis from whichto record data and promotes completeness and clarity in communication.AssessmentSafe, Effective Care Environment-Coordinated CareApplicationD)A client’s medical record documents the client’s ongoing status, regardless of thesystem or method used. The focus should be on the client, not on the nurse or otherhealthcare providers involved in the client’s care. The use of the nursing process asa guideline in documentation enables nurses to have a common basis from whichto record data and promotes completeness and clarity in communication.AssessmentSafe, Effective Care Environment-Coordinated CareApplication