1. Describe "Charting by Exception".
    Writing only abnormal findings usually documented on flow sheets, standards of nursing care, chart only abnormal findings, etc...
  2. Why is it important to keep a close watch on meds and the older adult?
    Liver and kidney functions of the older adult are important. Older patients on a lot of meds could possibly have an accumulation of meds in the body and some could be incompatible with one another.
  3. How are change of shift reports obtained?
    Recorded, Verbal, & Bedside
  4. Which charting rules will keep the nurse legally safe? SELECT ALL THAT APPLY.

    1. Use Military Time
    2. Document worries or concerns expressed by the client.
    3. Perform most of the charting at the end of the shift
    4. Record only information that pertans to the clients health problems.
    1, 2, 4. Option 3 is incorrect because charting should be done as events occur.
  5. A 75 y/o female is brough to the E.R c/o right hip pain. The right leg is shorten that the left and is externally rotated. During inspection the nrse ovserves that appears to be cigarette burns on the client's inner thighs. Which is the most appropriate documentation?

    1. Six round skin lesions partially healed, on the inner thighs bilaterally
    2. Several burned areas on both of the client's inner thighs
    3. Multiple lesions on inner thighs possibly related to elder abuse.
    4. Several lesions on inner thight similar to cigarette burns.
    1. Option 1 is the most accurate non judgemental charting.

    Chp. 15 # 9
  6. If the nurse makes an error while charting, which is the
    recommended method to correct the mistake?

    1.Draw one line through the error and write
    “mistaken entry” above it, then sign your name or initials beside

    2. Do nothing and hope no one notices the

    3. Use “correction fluid” and obliterate the error
    • 1. Draw a line through it and write the words "mistaken entry" above or next
    • to the original entry with your name or initials.

    • Do not erase, blot out, or use
    • correction fluid. Avoid writing the word "error" when recording that a mistake
    • has been made.

  7. Which framework is used when charting?

    1.Holistic framework

    2.Maslow’s Hierarchy of Needs

    3.Roy’s model and theory

    4.The nursing process
    4. The nursing process

    • Complete charting by using the steps of the nursing process as a framework is
    • the best defense against malpractice.

  8. What are the advantages of a problem-oriented medical record?

    1. It encourages collaboration, and it allows for
    easier tracking of the status of the client's problem.

    2. It allows for uniqueness in charting as different
    members have different styles of documenting.

    3. It provides more accuracy as staff members have to
    be constantly vigilant in maintaining an up-to-date list of problems and interventions.

    4. It is efficient as assessments and interventions
    are not repeated, and it encourages cooperation of team members
    1. It encourages collaboration, and it allows for easier tracking of the status of the client's problem.

    • The advantages of the problem-oriented medical record (POMR) are that it
    • encourages collaboration, and because the problem list is easily accessible, the
    • tracking of the client's problem status is easier.
Card Set
LECTURE 2--TEST I REVIEW-Documentation & Reporting Questions