Exam 4: Reporting and Recording

More than ________ % of sentinel events are caused by communication problems.

The physician has just visited the patient and is about to leave.The nurse informs the doctor that the patient has been complaining of intermittent but severe headaches and would like something for the pain.As the doctor is leaving the unit,he tells the nurse to give the patient acetaminophen 650 mg PO as needed,and to call him if it doesn't work.The doctor then leaves.The nurse should:

A delivery model that coordinates and links health care services to patients and families is:

The goal of information management is to: (Select all that apply.)

The patient has been in the hospital for 12 days.The nurse meets with the physical therapist,the case manager,the nutritionist,and other members of the team to discuss his progress and readiness to go home.This type of multidisciplinary meeting often is called:

The patient has a student nurse from Anyplace College (AC)caring for him this morning.On this unit,student nurses are not allowed to chart on their patient.The nurse should:

Of the following documentation systems,which involves writing a narrative note only when there is a change from an established norm?

"Patient is wheezing and is experiencing some dyspnea on exertion." This is an example of:

Which of the following is the best example of objective charting?

___________________ provide a format for documenting a record of a patient's health status and progress.

The American Nurses Association (ANA)guidelines and strategies for safe computer charting recommend: (Select all that apply.)

________________ measurements for patients on a unit serve as a guide for determining staffing needs.

One primary difference between home care and hospital care is that with home care:

The nurse manager is attempting to determine the staffing needs of the unit.One tool that she may use to determine the level of care needed would be:

The purpose of the patient's record is to provide information for: (Choose all that apply.)

The patient has been transferred to the nursing home from the acute care hospital.A report was called from the hospital and was received by the RN in charge of the nursing home unit.Upon arrival,the patient is assessed using:

When making written entries in the patient's medical record,describe the nursing care provided and the ____________.

The patient is a 24-year-old man who is diagnosed with possible HIV infection while being treated for active pneumonia.He has stated that the nurse may share test result information with his significant other but nothing else at this time.The nurse may:

A patient's private health information is legally protected by the ________________.

Nurse Smith gave a report to Nurse Jones and went home.After getting home,Nurse Smith remembered that she gave the patient morphine 2 mg IV but forgot to chart it in the progress note.She calls Nurse Jones to let her know and asks if Nurse Jones could chart it for her.Nurse Jones should: