RPN - Registered Practical Nurse Documentation and Reporting Questions and Answers — Questions and Answers
Question 1: An RPN makes an error while documenting a client's vital signs on a paper chart. Which action is the correct procedure for correcting this mistake?
- Use correction fluid to cover the error and write the correct information.
- Draw a single line through the incorrect entry, write 'error' or 'mistaken entry' above it with the nurse's initials, and then record the correct information. (Correct answer)
- Completely black out the error with a marker and chart the correct data in the next available space.
- Leave the error as is and add a new note at the end of the shift explaining the correction.
Correct answer: Draw a single line through the incorrect entry, write 'error' or 'mistaken entry' above it with the nurse's initials, and then record the correct information.
The professional and legal standard for correcting an error in a paper health record is to ensure the original entry remains legible. A single line is drawn through the error, it is labeled as an error with the nurse's initials, and the correct information is added. This maintains the integrity and transparency of the legal document.
Question 2: An RPN is calling a physician to report a client's sudden onset of shortness of breath. Using the SBAR communication tool, which of the following statements represents the 'Assessment' component?
- "The client was admitted yesterday with a fractured hip and has no history of respiratory issues."
- "I request an order for a portable chest x-ray and for you to come assess the client immediately."
- "This is Nurse Lee calling from Unit 4 about Mr. Chen in room 402B, who is experiencing new-onset dyspnea."
- "I believe the client may be experiencing a pulmonary embolism as his oxygen saturation is 88% on room air and he is tachycardic." (Correct answer)
Correct answer: "I believe the client may be experiencing a pulmonary embolism as his oxygen saturation is 88% on room air and he is tachycardic."
The 'Assessment' part of SBAR involves the nurse stating their professional conclusion about the situation. Stating "I believe the client may be experiencing a pulmonary embolism" synthesizes the available data (shortness of breath, low oxygen) into a potential clinical problem, which is the core of the assessment step.
Question 3: Which of the following documentation entries is the best example of objective data?
- "Client seems depressed and is refusing to eat lunch."
- "Client had a good day and was pleasant to staff."
- "Abdominal dressing is dry and intact with no erythema or swelling noted at the incision site." (Correct answer)
- "Client is complaining of severe pain and appears uncomfortable."
Correct answer: "Abdominal dressing is dry and intact with no erythema or swelling noted at the incision site."
Objective data is factual information that is observed, measured, or felt by the healthcare provider. The description of the abdominal dressing is based on direct observation and is not subject to interpretation. The other options include subjective terms ('seems depressed,' 'good day,' 'complaining,' 'appears uncomfortable').
Question 4: An RPN realizes they forgot to document a medication that was administered two hours prior. What is the proper procedure for adding this information to the client's electronic health record?
- Ask a colleague to enter the medication documentation for them.
- Create a new entry, clearly labeled as a 'late entry,' and record the actual time the medication was administered. (Correct answer)
- Document the medication as if it were just given at the current time.
- Wait until the next shift to see if the oncoming nurse can add the entry.
Correct answer: Create a new entry, clearly labeled as a 'late entry,' and record the actual time the medication was administered.
When documenting care after the fact, it is critical to identify the note as a 'late entry.' This ensures the chronological integrity and accuracy of the medical record. The entry should include the current date and time of documentation as well as the specific date and time the care was actually provided.
Question 5: An RPN is caring for a client who had a fall. The RPN completes an incident report according to facility policy. How should this event be documented in the client's official health record?
- Document a factual account of the fall, the client's response, and the interventions performed, without mentioning the incident report. (Correct answer)
- Write "Incident report completed and filed with risk management" in the progress notes.
- Place a copy of the incident report in the client's chart for the physician to review.
- Only document the fall in the incident report to prevent legal discovery of the event.
Correct answer: Document a factual account of the fall, the client's response, and the interventions performed, without mentioning the incident report.
The client's health record should contain objective, factual information about the event (the fall), the assessment findings, and the care provided. The incident report is an internal risk management tool and should not be mentioned or included in the patient's chart.
Question 6: According to Ontario's Personal Health Information Protection Act (PHIPA), an RPN understands that they can access a client's personal health information under which of the following circumstances?
- When a colleague from another unit asks about the client's diagnosis out of curiosity.
- Only when it is necessary for the direct provision of care to that specific client. (Correct answer)
- If the client is a family member and the RPN wants to check on their progress.
- To review the chart of an interesting case on the unit for educational purposes.
Correct answer: Only when it is necessary for the direct provision of care to that specific client.
PHIPA and CNO standards dictate that nurses must only access personal health information for which they have a professional purpose. This is often referred to as being within the 'circle of care.' Accessing information out of curiosity, for personal reasons, or for general education without authorization is a breach of privacy.
