Documentation and Reporting Flashcards

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?

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.

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?

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.

Which of the following documentation entries is the best example of objective data?

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').

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?

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.

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?

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.

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?

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.