Documenting and Reporting

Notes

Documentation
  • Serves as a permanent record of client information and care.
Reporting
  • Takes place when two or more people share information about client care, either face to face or by telephone
Guidelines for Good Documentation and Reporting
  1. Fact – information about clients and their care must be factual. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells
  2. Accuracy – information must be accurate so that health team members have confidence in it
  3. Completeness – the information within a record or a report should be complete, containing concise and thorough information about a client’s care. Concise data are easy to understand
  4. Currentness – ongoing decisions about care must be based on currently reported information.
    1. At the time of occurrence include the following:
      1. Vital signs
      2. Administration of medications and treatments
      3. Preparation of diagnostic tests or surgery
      4. Change in status
      5. Admission, transfer, discharge or death of a client
      6. Treatment fro a sudden change in status
  5. Organization – the nurse communicate in a logical format or order
  6. Confidentiality – a confidential communication is information given by one person to another with trust and confidence that such information will not be disclosed
Documentation
  • Anything written or printed that is relied on as a record of proof fro authorized persons.
Purposes of Records
  1. Communication
  2. Planning Client Care
  3. Auditing Health Agencies
  4. Research
  5. Education
  6. Reimbursement
  7. Legal Documentation
  8. Health Care Analysis
Documentation Systems
  1. Source – Oriented Record
    1. The traditional client record
    2. Each person or department makes notations in a separate section or sections of the client’s chart
    3. It is convenient because care providers from each discipline can easily locate the forms on which to record data and it is easy to trace the information
    4. Example: the admissions department has an admission sheet; the physician has a physician’s order sheet, a physician’s history sheet & progress notes
    5. NARRATIVE CHARTING is a traditional part of the source-oriented record
  2. Problem – Oriented Medical Record (POMR)
    • Established by Lawrence Weed
    • The data are arranged according to the problems the client has rather than the source of the information.
      1. The four (4) basic components:
        1. Database – consists of all information known about the client when the client first enters the health care agency. It includes the nursing assessment, the physician’s history, social & family data
        2. Problem List – derived from the database. Usually kept at the front of the chart & serves as an index to the numbered entries in the progress notes. Problems are listed in the order in which they are identified &    the list is continually updated as new problems are identified & others resolved
        3. Plan of Care – care plans are generated by the person who lists the problems. Physician’s write    physician’s orders or medical care plans; nurses write nursing orders or nursing care plans
        4. Progress Notes – chart entry made by all health professionals involved in a client’s care; they all use the same type of sheet fro notes. Numbered to correspond to the problems on the problem list and may be lettered for the type of data
      2. Example: SOAP Format or SOAPIE and SOAPIER
        • S – Subjective data
        • O – Objective data
        • A – Assessment
        • P – Plan
        • I – Intervention
        • E – Evaluation
        • R- Revision
    • Advantages of POMR:
      • It encourages collaboration
      • Problem list in the front of the chart alerts caregivers to the client’s needs & makes it easier to track the status of each problem.
    • Disadvantages of POMR:
      • Caregivers differ in their ability to use the required charting format
      • Takes constant vigilance to maintain an up-to-date problem list
      • Somewhat inefficient because assessments & interventions that apply to more than one problem must be repeated.
  3. PIE (Problems, Interventions, and Evaluation)
    1. Groups information in to three (3) categories
    2. This system consists of a client care assessment floe sheet & progress notes
    3. FLOW SHEET – uses specific assessment criteria in a particular format, such as human needs or functional health patterns
    4. Eliminate the traditional care plan & incorporate an ongoing care plan into the progress notes
  4. Focus Charting
    1. Intended to make the client & client concerns & strengths the focus of care
    2. Three (3) columns fro recording are usually used: date & time, focus & progress notes
  5. Charting by Exception
    1. Documentation system in which only abnormal or significant findings or exceptions to norms are recorded
    2. Incorporates three (3) key elements:
      1. Flow sheets
      2. Standards of nursing care
      3. Bedside access to chart forms
  6. Computerized Documentation
    1. Developed as a way to manage the huge volume of information required in contemporary health care
    2. Nurses use computers to store the client’s database, add new data, create & revise care plans & document client progress.
  7. Case Management
    1. Emphasizes quality, cost-effective care delivered within an established length of stay
    2. Uses a multidisciplinary approach to planning & documenting client care, using critical pathways.
Nursing Care Plan (NCP)
Two Types:
  1. Traditional Care Plan – written fro each client; it has 3 columns: nursing diagnoses, expected outcomes & nursing interventions.
  2. Standardized Care Plan – based on an institution’s standards of practice; thereby helping to provide a high quality of nursing care
KARDEX
  • Widely used, concise method of organizing & recording data about a client, making information quickly accessible to all health professionals. Consists of a series of cards kept in a portable index file or on computer generated forms.

Information may be organized into sections:

  1.  Pertinent information about the client
  2. List of medications
  3. List of IVF
  4. List of daily treatments & procedures
  5. List of Diagnostic procedures
  6. Allergies
  7. Specific data on how the client’s physical need is to be met
  8. A problem list, stated goals & list of nursing approaches to meet the goals
Nursing Discharge / Referral Summaries
  • Completed when the client is being discharged & transferred to another institution or to a home setting where a visit by a community health nurse is required. Regardless of format, it includes some or all of the following:
  1. Description of client’s physical, mental & emotional state
  2. Resolved health problems
  3. Unresolved continuing health problems
  4. Treatments that can be continued (e.g. wound care, oxygen therapy)
  5. Current medications
  6. Restrictions that relate to activity, diet & bathing
  7. Functional/self-care abilities
  8. Comfort level
  9. Support networks
  10. Client education provided in relation to disease process
  11. Discharge destination
  12. Referral Services (e.g. social worker, home health nurse)

 

Exam

Welcome to your Documentation & Reporting! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

 

Exam Details

  • Number of Questions: 37 items
  • Mode: Practice Mode

Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

 

Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Consider the format and content of the documentation. It appears to be a detailed description of a patient's condition, presented in a continuous flow, without any specific structure or headings. This form of documentation is used to tell a story about the patient's experience and condition.

1 / 37

1. Nurse Thompson is reviewing a piece of documentation that reads: "Pain scale 0/10, hand and leg strong to right, weak to left. Skin pink, warm and dry, turgor good, incision to Rt. anterior chest wall without erythema or edema ………….Jane Night, LPN." She wants to identify the type of documentation she is looking at. What kind of documentation is the following?

💡 Hint

Consider which method is designed to assess the severity of a patient's condition, allowing for prioritized care based on individual needs. The correct answer involves an approach that classifies patient conditions systematically.

2 / 37

2. Nurse James is responsible for prioritizing patient care on a busy intensive care unit. To help organize his workload and ensure that the most critically ill patients receive timely care, he refers to a specific method of charting that rates each patient by the severity of their illness. Which of the following nursing charting methods utilizes a scoring system to rate each patient by their illness severity?

💡 Hint

An incident report should stick to the facts and avoid personal interpretations or judgments. Consider what information should be recorded objectively and what might lead to bias or misunderstanding.

3 / 37

3. While working the night shift, Nurse Thomas notices that a patient has fallen out of bed. After assessing the patient and notifying the physician, he needs to fill out an incident report. As he completes the form, reflecting on the necessary components to include, which of the following should Nurse Thomas NOT consider?

💡 Hint

Think about the specific tools or systems that would be directly associated with assessing and standardizing care in Long Term Care facilities. The correct answer is linked to the evaluation and planning of patient care in such settings.

4 / 37

4. Nurse Emily is attending a workshop on regulations and requirements for Long Term Care facilities. The facilitator discusses various acts and their implications, including the Omnibus Budget Reconciliation Act. Nurse Emily learns that one specific tool or system is primarily required by this act for Long Term Care facilities. Which of the following is it?

💡 Hint

Focus on the option that refers to a systematic approach to patient care, often used to guide nursing interventions based on specific diagnoses or needs. It's a standardized method used across various nursing settings.

5 / 37

5. Nurse Adams is referring to a system developed by nurses for nurses, centered on nursing diagnoses and assessments. This approach encompasses goals, care plans, and detailed actions for the implementation and evaluation of care. What is this system known as?

💡 Hint

The correct answer refers to a system that classifies hospital cases into one of the originally predefined groups, considering diagnoses and other factors, to determine payment. This method is often used by government plans to reimburse healthcare providers.

6 / 37

6. Nurse Edwards is involved in administrative tasks at a local hospital and comes across a discussion regarding cost reimbursement rates by government plans. She remembers that there's a specific term that defines the main basis for this reimbursement. What is the main basis for cost reimbursement rates by government plans?

💡 Hint

Focus on how Traditional and Problem-Oriented Medical Record (POMR) Charting approach information structure. One system employs a more flowing, continuous style, while the other applies a structured, organized approach to documenting patient information.

7 / 37

7. During a training session on medical charting, Nurse Mitchell is exploring the differences between Traditional and Problem-Oriented Medical Record (POMR) Charting. She identifies the correct differentiation. What is the difference between Traditional and Problem-Oriented Medical Record Charting?

💡 Hint

Consider the fundamental elements that are unique to problem-oriented medical records. Among the options, one pertains to a different aspect of patient care and is not usually encompassed in the main sections of a POMR.

8 / 37

8. Nurse Jackson is reviewing the sections of a problem-oriented medical record (POMR) as part of her ongoing professional development. She knows that certain sections are typical of a POMR, while others are not. Which of the following are considered the main parts of a problem-oriented medical record EXCEPT?

💡 Hint

Consider the foundational principles behind each of these charting methods. One of them focuses on a nursing model that emphasizes patient problems and interventions, while the other adopts a more medical model that includes both subjective and objective observations.

9 / 37

9. Nurse Thompson is studying different charting methods and wants to understand the essential difference between the PIE (Problem, Intervention, Evaluation) and SOAPE (Subjective, Objective, Assessment, Plan, Evaluation) formats. What is the core distinction between these two approaches?

💡 Hint

Charting by Exception focuses on documenting deviations or exceptions from the standard, such as new problems or unresolved issues. Reflect on what happens once an issue has been resolved, considering the nature of CBE.

10 / 37

10. Nurse Peterson is implementing "Charting by Exception" (CBE) in her documentation, and she's considering what happens after a patient's problem has been resolved. In charting by exception, what is the proper procedure once a patient's problem is no longer an issue?

💡 Hint

Consider the best practices in correcting errors in documentation. One of the options is aligned with proper correction procedures and would not typically be considered an action that could lead to malpractice.

11 / 37

11. Nurse Harrison is attending a seminar on avoiding malpractice in healthcare documentation. The facilitator is highlighting practices that could potentially lead to malpractice. Nurse Harrison identifies one statement that does NOT pertain to actions leading to malpractice. Which of the following practices could lead to malpractice EXCEPT?

💡 Hint

Reflect on the flexibility of the DARE format. One of the options describes an inflexible approach that is not typically required when using the DARE steps in documentation.

12 / 37

12. Nurse Lewis is learning about the DARE format of documentation and is examining several statements to determine which one is incorrect. The following statements regarding the DARE format of documentation are correct EXCEPT?

💡 Hint

Consider the nature of home health care, where patient care must be carefully tracked and coordinated. The correct statement conflicts with the necessity for careful and thorough documentation in this setting.

13 / 37

13. Nurse Ethan is participating in a training session on home health care. During the session, various aspects of home health care, including its demands and scope, are discussed. As he listens, he identifies one statement that is NOT true about home health care. Which of the following statements is NOT true?

💡 Hint

Consider the main principles of FOCUS CHARTING. One of the options misrepresents this method by associating it with something that's not typically part of the FOCUS in nursing documentation.

14 / 37

14. Nurse Anderson is reviewing FOCUS CHARTING as part of her ongoing training. She wants to identify the incorrect statement about this particular type of charting. Which of the following statements about FOCUS CHARTING is incorrect?

💡 Hint

Think about the legal requirements for transparency and accountability in medical documentation. Which action would fail to provide a clear and traceable record of any changes made?

15 / 37

15. Nurse Baxter is reviewing the legal guidelines for documentation in the medical ward. Understanding the right practices for correcting and handling patient records is essential. Which of the following corrective actions is incorrect based on legal guidelines for documentation?

💡 Hint

Reflect on the system used by the government to determine reimbursement rates for healthcare providers, specifically related to Medicare and Medicaid. The correct answer involves a classification system that standardizes payment based on diagnosis and procedures.

16 / 37

16. Nurse William is attending a seminar on healthcare reimbursement systems, focusing on Medicare and Medicaid. The speaker explains the basis on which the government reimburses agencies for healthcare costs incurred by recipients of these programs. William reviews his notes to clarify his understanding. How does the government reimburse agencies for healthcare costs incurred by Medicare and Medicaid recipients?

💡 Hint

Think about the document that outlines specific care actions and assessments for patients with particular health needs. This tool is often used to provide individualized care based on diagnoses or conditions.

17 / 37

17. Nurse Thompson is seeking a tool that consists of preprinted guidelines tailored to care for patients who have comparable health issues. Which option correctly identifies this tool?

💡 Hint

Think about the standard form used in healthcare settings to record unusual or unexpected events that could lead to harm or violate standard procedures. It's a vital part of risk management and quality control.

18 / 37

18. During Nurse Johnson's shift, an unexpected event occurs that is not consistent with the routine operation of the healthcare unit or the standard care of a patient. This event has the potential to lead to injury. In line with hospital protocols and national standards, what must Nurse Johnson complete to document this occurrence?

💡 Hint

Think about the terms specifically related to writing or making notations in medical records. One of these tasks typically involves inputting information electronically, rather than adding written information to the record.

19 / 37

19. During a busy shift at the city hospital, Nurse Thompson is keeping track of patient information. She knows that maintaining accurate healthcare records is vital. Among her duties, she must avoid one task that doesn't pertain to adding written information to a healthcare record. Which of the following does NOT refer to the process of adding written information to a healthcare record?

💡 Hint

Reflect on the primary goals of maintaining patient records in a healthcare setting. One of the options outlines a purpose that is not generally aligned with the ethical considerations and core objectives of patient care.

20 / 37

20. During her orientation, Nurse Mitchell is learning about the importance of accurate and complete written patient records. She's taught various purposes for maintaining these records but recalls one that doesn't align with standard nursing practices. Which of the following are basic purposes for accurate and complete written patient records EXCEPT?

💡 Hint

Reflect on the core function and advantages of 24-hour patient care records. One option mentions something vital but not directly linked to the utilization of these specific records within the nursing practice.

21 / 37

21. Nurse Lisa, working on a bustling medical-surgical ward, commences her shift by meticulously going through the 24-hour patient care records. As she assimilates the status and unique needs of her patients from these documents, she ponders the benefits of maintaining such records. Which of the following is NOT considered a benefit of employing 24-hour patient care records within the nursing setting?

💡 Hint

Consider what HIPAA's primary role is in healthcare. It involves the protection of patients' personal health information, ensuring that the data remains secure and accessible only to those authorized to view it. The correct answer aligns with this fundamental aspect of the act.

22 / 37

22. Nurse Jacob is conducting a workshop on legal compliance within healthcare, focusing on the Health Insurance Portability and Accountability Act (HIPAA). He emphasizes the critical mandates that HIPAA enforces concerning patients' records. A fellow healthcare worker asks for clarification on what exactly HIPAA mandates healthcare personnel to ensure with regards to patients' records. What is the correct answer?

💡 Hint

Consider the charting method that involves a chronological, continuous, descriptive account of the patient's condition and response to treatment without the use of specialized formats. This approach is often considered the traditional way of documenting patient care in nursing.

23 / 37

23. Nurse Wilson is attending a workshop on various charting methods. She's focusing on identifying what constitutes traditional charting in the nursing field. Which of the following is considered a traditional charting method?

💡 Hint

Think about the principles of patient confidentiality and privacy, especially in light of laws such as HIPAA. The correct answer should align with these principles, ensuring that unauthorized access to patient information is prevented.

24 / 37

24. During clinical rotations, Nurse James is shadowing his nurse preceptor when she has to suddenly leave her station in response to a code announced over the public address system. James observes that the computer monitor is displaying a patient's medical history, and this patient is not under his care or supervision. What is the most appropriate action for James to take next?

💡 Hint

Charting by Exception focuses on abnormal findings or deviations from the standard. Think about which option might be part of regular, comprehensive charting but not specifically emphasized in the CBE method.

25 / 37

25. Nurse Johnson is utilizing the "Charting by Exception" (CBE) method, which focuses on documenting abnormal findings or exceptions to the established norms. She is examining different aspects that may be documented using this approach. What kind of notes are typically taken when charting by exception EXCEPT?

💡 Hint

Acuity charting is used to gauge the intensity of nursing care required for a patient. Reflect on how this information could impact staffing decisions and needs in a specific nursing unit.

26 / 37

26. Nurse Allison is preparing the staffing schedule for the upcoming week in the cardiac care unit. She refers to acuity charting to understand the needs and severity levels of the patients. As she plans, she realizes that one of the benefits of acuity charting is that it provides the ability to determine efficient staffing patterns according to the acuity levels of the patients in her particular unit. Is this statement true or false?

💡 Hint

Think about the flexibility and customization of clinical pathways. One statement here contradicts the idea that these tools might be adapted to fit the unique requirements and practices of individual healthcare institutions.

27 / 37

27. Nurse Maya is at a healthcare conference, absorbing information about Clinical or Critical Pathways. She comes across several insights regarding their use in coordinated care, but one statement doesn't align with her understanding. Which of the following statements about Clinical or Critical Pathways is NOT true?

💡 Hint

Think about the forms that are directly related to patient care, including patient assessments, care planning, and monitoring. One of these options is not specific to healthcare record-keeping and instead pertains to a different aspect of daily operations.

28 / 37

28. During a training session, Nurse Adams is learning about different types of record-keeping forms used in patient care. Among the following options, which one is NOT considered an example of record-keeping forms in a healthcare setting?

💡 Hint

Consider the method that records only significant findings or exceptions, making documentation more efficient. What abbreviation matches this description?

29 / 37

29. Nurse Mitchell faces the challenge of meeting legal requirements at a facility that mandates narrative notes for each shift, requiring at least three entries. While this approach ensures accountability, it can be time-consuming and demands excessive detail. To address this issue, some hospitals have adopted a more efficient method. What method did some hospitals come up with?

💡 Hint

Focus on the statements that describe genuine errors or inappropriate practices in documentation. One of the options discusses a method that, although it might be less common, doesn't inherently represent a form of inadequate documentation.

30 / 37

30. Nurse Parker is participating in a workshop about avoiding inadequate documentation in her healthcare facility. A discussion arises about common forms of poor documentation, but one statement doesn't belong. Which of the following statements about common forms of inadequate documentation should NOT be included?

💡 Hint

Consider which type of healthcare facility would be governed by federal laws and regulations that might grant patients immediate access to their records. The correct answer relates to a system that serves a specific population and operates under federal guidelines.

31 / 37

31. Nurse Olivia is instructing a group of nursing students about patient rights and access to medical records. She explains that patients usually do not have immediate access to their full records, but there is an exception. One of the students asks her to clarify this exception. What is the exception to the general rule that patients do not have immediate access to their full records?

💡 Hint

Consider the forms in which nursing documentation is usually accepted. One of the options mentions a method that is not typically recognized as a standard practice in documenting patient care.

32 / 37

32. Nurse Williams is diligently documenting patient care at the end of her shift at the community health center. While she understands the importance of proper documentation, she recalls a statement from her training that is not true about this essential nursing practice. Which of the following statements about documenting is NOT true?

💡 Hint

Think about the proper procedure for handling a patient's request for medical records, including the need to ensure confidentiality and adherence to regulations. The correct response aligns with legal and ethical considerations.

33 / 37

33. Nurse Daniel overhears an irate patient at the clinic's front desk, complaining to a clerk about the cost of physical examinations and demanding immediate access to their medical records. The patient believes they have a right to their medical files and needs them right away. What would be the most appropriate response to the patient's request?

💡 Hint

Think about the element that systematically organizes a patient's problems and serves as a guide for the healthcare team. This component provides a quick reference to the patient's health status and the care needed, often within a problem-oriented medical record.

34 / 37

34. Nurse Thompson is learning about different components of charting documentation, particularly focusing on a part that includes active, inactive, potential, and resolved problems. This part serves as the index for charting documentation. What is being described?

💡 Hint

Consider the importance of security and confidentiality in healthcare, especially when dealing with sensitive patient information. The correct answer aligns with the best practices for ensuring that only authorized personnel can access Electronic Medical Records.

35 / 37

35. Nurse Sarah is providing training to new healthcare personnel about the importance of Electronic Medical Records (EMRs) and their proper use. During the training, she emphasizes the specific requirement that EMRs have concerning access and security. What do Electronic Medical Records require from healthcare personnel?

💡 Hint

Reflect on a system that serves the specific purpose of bringing together critical information about a patient's care needs, medications, and specific orders, making it readily available to healthcare providers. This tool is often stationed near nursing areas and is vital in many healthcare environments.

36 / 37

36. Nurse Williams is in search of a specific system within the healthcare facility that efficiently consolidates all patient orders and essential care requirements in one centralized, succinct location. Which of the following options refers to this highly-utilized system?

💡 Hint

Consider what information in narrative charting could indicate a significant change in the patient's condition. The correct answer relates to an aspect of care that may require further intervention.

37 / 37

37. Nurse Emily is teaching a group of nursing students about the importance of narrative charting in patient care. She emphasizes specific instances when narrative notes are essential. One student asks, "What needs to be charted in a narrative note among the following scenarios?" Which of the following is necessary to document in a narrative note?

Presentation