Documenting and Reporting > Fundamentals
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Documentation and Reporting
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is reviewing the documentation and reporting policies of a healthcare facility.
The nurse understands that documentation serves as a permanent record of patient information, data, and care.
Which of the following is another purpose of documentation?
Explanation
To communicate with other healthcare providers about the patient’s needs and progress.
Documentation in nursing serves several purposes, including providing continuity of care for patients, determining clinical reimbursement, avoiding malpractice, and facilitating communication between rotating providers.It is also used to determine the severity of illness, the intensity of services, and the quality of care provided upon which payment or reimbursement of health care services is based.
Choice A is wrong because documentation is not meant to provide evidence of malpractice in case of a lawsuit, but rather to avoid it by following the guidelines and standards of nursing practice.
Choice C is wrong because documentation is not the only purpose of evaluating the quality and effectiveness of the care provided.There are other methods and tools for quality improvement, such as audits, surveys, feedback, etc.
Choice D is wrong because documentation is not the only purpose of justifying the reimbursement for the services rendered.There are other factors and criteria that determine the reimbursement rates, such as diagnosis-related groups, case mix index, etc.
Normal ranges for documentation vary depending on the type, format, and frequency of documentation.
However, some general principles for documentation are:.
• It should be clear, accurate, and accessible.
• It should reflect the nursing process (assessment, planning, implementation, and evaluation).
• It should use standardized terminologies and abbreviations.
• It should be completed in real time or as soon as possible after care delivery.
• It should include all relevant patient information and data.
• It should comply with the legal and ethical requirements of nursing practice.
A nurse is preparing to report the status of a patient to another nurse during a shift change.
The nurse should include which of the following information in the report?
(Select all that apply.).
Explanation
The nurse should include the patient’s name, age, and diagnosis, the patient’s current vital signs and pain level, the patient’s preferences and goals for care, and the patient’s plan of care and any pending interventions in the report.
These are the most relevant and important information that the oncoming nurse needs to know to provide safe and effective care for the patient.
Choice D is wrong because the patient’s family history and social support are not essential to include in the report.
They may be part of the patient’s medical record, but they are not likely to change during the shift or affect the patient’s immediate needs.
A nursing shift report is a document that a nurse writes about their patients at the end of their shift to give to the nurse tending to their patients on the next shift.
It helps the oncoming nurse understand the patient’s medical conditions, needs, and progress.It also helps ensure continuity of care and prevent errors or omissions.
Normal ranges for vital signs vary depending on age, gender, and health status, but generally they are:.
• Temperature: 36.5°C to 37.2°C (97.7°F to 99°F).
• Pulse: 60 to 100 beats per minute.
• Respiration: 12 to 20 breaths per minute.
• Blood pressure: less than 120/80 mmHg.
• Pain level: 0 to 10 on a numerical scale or using a visual analog scale.
A nurse is documenting the care provided to a patient who has a wound infection.
The nurse writes: “The wound was cleansed with normal saline and covered with a sterile dressing.
No signs of redness, swelling, or drainage were noted.” Which of the following statements reflects the nurse’s use of objective data?
Explanation
“The wound was cleansed with normal saline and covered with a sterile dressing.” This statement reflects the nurse’s use of objective data because it describes what the nurse did and observed using the five senses.Objective data is factual information that professionals gather through observation or measurement that is true regardless of the feelings or opinions of the person presenting or receiving the information.
Choice B is wrong because it also contains objective data.
The nurse observed the wound and did not see any signs of inflammation or infection.
Choice C is wrong because it contains subjective data.The patient stated how they felt about the wound, which is their perception, feeling, or concern.
Choice D is wrong because it also contains subjective data.The nurse inferred how the patient appeared, which is their opinion or interpretation.
Normal ranges for wound healing depend on various factors, such as the type, size, location, and severity of the wound, as well as the patient’s age, health status, nutrition, and infection risk.
Generally, wounds go through four phases of healing: hemostasis, inflammation, proliferation, and maturation.
Hemostasis occurs immediately after injury and involves blood clotting and vasoconstriction.
Inflammation lasts for 3 to 5 days and involves swelling, redness, pain, and immune response.
Proliferation lasts for 2 to 24 days and involves granulation tissue formation, wound contraction, and epithelialization.Maturation lasts for 21 days to 2 years and involves collagen remodeling and scar formation.
A nurse is caring for a patient who has a history of depression and is taking an antidepressant medication.
The nurse asks the patient how he is feeling today.
The patient responds: “I don’t know, I guess I’m okay.” Which of the following statements by the nurse is an appropriate response?
Explanation
Tell me more about how you are feeling.
This statement by the nurse is an appropriate response because it shows empathy, interest, and respect for the patient’s feelings.
It also encourages the patient to express his emotions and thoughts, which can help the nurse assess the severity of his depression and the effectiveness of his medication.Asking open-ended questions is a therapeutic communication technique that can facilitate rapport and trust between the nurse and the patient.
Choice A is wrong because it implies doubt and criticism of the patient’s response.
It may make the patient feel defensive or invalidated.
Choice B is wrong because it assumes that the patient is feeling better without verifying it.
It may also contradict the patient’s reality and discourage him from sharing his true feelings.
Choice D is wrong because it places unrealistic expectations on the patient and minimizes his struggle.
It may also imply that the patient is not trying hard enough or that his medication is not working.
Antidepressant medications are used to alter the concentration of neurotransmitters in the brain that are responsible for mood regulation, such as serotonin, norepinephrine, and dopamine.They can help relieve symptoms of depression, such as low mood, anhedonia, guilt, worthlessness, low energy, poor concentration, appetite changes, sleep disturbances, and suicidal thoughts.
However, antidepressant medications are not a cure for depression and they do not work immediately.They usually take several weeks to reach their full effect and they may cause side effects such as nausea, headache, weight gain, sexual dysfunction, and increased risk of bleeding.
Nursing care for patients taking antidepressant medications involves assessing and monitoring their depressive symptoms, suicidal thoughts, mental status, vital signs, weight, serum electrolytes, kidney and liver function, and pregnancy status.Nurses should also facilitate regular psychotherapy sessions, provide education on depression management, encourage adherence to medication regimen, teach coping skills and stress management techniques, promote healthy lifestyle habits such as exercise, nutrition, and sleep hygiene, and provide emotional support and encouragement.
A nurse is using a computer-based system to document the care provided to a patient who has diabetes mellitus.
The nurse enters the patient’s blood glucose level, insulin dose, dietary intake, and urine output.
The system automatically generates a graph that shows the trends and patterns of these data over time.
This type of documentation system is known as:.
Explanation
Flow sheet charting.
This type of documentation system uses graphs, tables, or checklists to record data that can be easily visualized and compared over time.Flow sheet charting is especially useful for documenting vital signs, blood glucose levels, intake and output, and other routine or repetitive measurements.
Choice A is wrong because narrative charting is a type of documentation system that uses descriptive sentences or paragraphs to record patient information.Narrative charting is often time-consuming and may include irrelevant or redundant details.
Choice B is wrong because problem-oriented charting is a type of documentation system that organizes patient information around specific problems or diagnoses.Problem-oriented charting typically uses the SOAP format (subjective, objective, assessment, plan) or its variations (SOAPIE, SOAPIER) to document the patient’s status and progress.
Choice C is wrong because charting by exception is a type of documentation system that only records abnormal or significant findings or deviations from pre-established standards or norms.Charting by exception assumes that everything is normal unless otherwise documented.
Normal ranges for blood glucose levels are 70 to 130 mg/dL before meals and less than 180 mg/dL two hours after meals.Normal ranges for urine output are 0.5 to 1 mL/kg/hour for adults and 1 to 2 mL/kg/hour for children.
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