COMMUNICATION FOR CONTINUITY AND COLLABORATION
Skill 9-1 MAKING ENTRIES IN A CLIENT’S RECORD
(continued) Assessment
Review the agency’s policy for the type of charting it uses.
Locate the agency’s list of approved abbreviations.
Determine the paper form that is appropriate to use for documenting the information or locate the file within an electronic record used for nursing documentation via a computer.
Check that the client’s name is identified on the chart form or computer file.
Planning
Resolve to document information as soon as it is obtained or at least every 1 to 2 hours.
Use a pen or keyboard to make entries; use the color of ink indicated by agency policy.
Implementation Record the date and time.
Write, print, or type information so it can be read easily.
Take care that keyboarding is accurate when a computer is used.
Use accurate spelling and grammar.
Be brief but complete; delete articles (a, an, the).
Do not state the client’s name; do not use pt.as an abbreviation for “patient.”
Use only agency-approved abbreviations and symbols.
Document information clearly and accurately without any subjective interpretation. Quote the client if a statement is pertinent.
Avoid phrases such as “appears to be” or “seems to be.”
Never use ditto marks.
Identify actual or approximate sizes when describing assessment data rather than using relative descriptions such as large, moderate, or small.
Some agencies require personnel to use a specific style (e.g., SOAP charting, narrative charting, PIE charting) for documentation.
Abbreviations used must be compatible with those that have been approved for legally defensible reasons.
Data obtained initially from the client is entered on the admission form; periodic additions about the client’s condition and care are entered on a form commonly called nurses’ notes or on a progress sheet. A graphic sheet or flow sheet is used to document numbers or trends in assessment data.
If a sheet of paper becomes separated from the chart, proper identification ensures that it is reinserted into the appropriate record. Electronic records are opened and stored using the client’s name.
The potential for inaccuracies or omissions increases when documentation is delayed.
Ink is permanent. Black ink photocopies better than other colors.
Information is recorded in chronologic order. The time of documentation is when the notation is written. Legal issues often involve the timing of events.
The entry loses its value for exchanging information if it is unreadable. Illegible entries become questionable in a court of law.
Literacy skills reflect a person’s knowledge and education.
Extra words add length to the entry.
It is understood that all the entries refer to the person identified on the chart form.
Using approved abbreviations promotes consistent interpretation.
The chart is a record of facts, not opinions.
Phrases implying uncertainty suggest that the nurse lacks reasonable knowledge.
Even if information is repetitious, it must be documented separately.
Nonspecific measurements are subject to wide interpretation and are therefore less accurate and informative.
SUGGESTED ACTION REASON FOR ACTION
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MAKING ENTRIES IN A CLIENT’S RECORD
(Continued)Documentation may be necessary to demonstrate that the nurse acted reasonably and that the care was not substandard.
Ensures continuity in preparing the client for discharge.
Filling space reduces the possibility that someone else will add information to the current documentation.
Making early entries can cause legal problems especially if the client’s condition suddenly changes.
Frequent charting indicates that the client has been observed and attended to at reasonable periods.
Correlating time with actual events promotes logic and order when evaluating the client’s progress.
Corrections are done in such a way that all words are readable. Obliterated words can cast suspicion that the record was tampered with to conceal damaging information.
A jury seeing the word error without any explanation might assume that the nurse made an errorin care rather than documentation.
The signature demonstrates accountability for what has been written.
Logging off returns the computer to a home or menu page, which prevents anyone else from entering information under the name of the person who originally logged in.
Exiting to a home or menu page prevents those who are unauthorized from viewing anything confidential on the computer screen.
Implementation (Continued)
Record adverse reactions; include the measures used to manage them.
Identify the specific information that is taught and the evidence of the client’s learning.
Fill all the space on each line of the form; draw a line through any blank space on an unfilled line.
Never chart nursing activities before they have been performed.
Follow agency policy for the interval between entries.
Indicate the current time when charting a late entry (documentation of information that occurred earlier but was accidentally omitted); write “late entry for. . . . .”
identifying the date and time to which the documentation refers.
Draw a line through a mistake rather than scribbling through or in any other way obscuring the original words.
Put the word error followed by a date and initials next to the entry and immediately enter the corrected information.
Some agencies specify that the nurse must indicate the nature of the error (e.g., “wrong medical record”).
Sign each entry with a first initial, last name, and title.
Log off the computer after documenting in an electronic client record.
Evaluation
The writer’s entries are
• Dated and timed
• Accurate, comprehensive, and up-to-date
• Legibly written according to the agency’s format
• Spelled correctly without grammatical errors
• Objectively written
• Free of unapproved abbreviations
• Identified with the writer’s name and title
SAMPLE DOCUMENTATION
Date and Time Dressing changed. Abdominal incision and sutures are intact. No evidence of redness, swelling, or
drainage. SIGNATURE/TITLE
SECTION I: REVIEWING WHAT YOU’VE LEARNED
Activity A: Fill in the blanks by choosing the correct word from the options given in parentheses.
1. The domain is a learning style through which information is presented in such a way as to appeal to a person’s feelings, beliefs, or values. (affective, cognitive, psychomotor)
2. Charting by exception is a documentation method in which nurses chart only assessment findings. (abnormal, physical, psychological)
3. includes nonverbal components such as facial expressions, posture, gestures, and body movements. (Kinesics, Paralanguage, Proxemics)
4. is the technique of restating what the client has said to demonstrate listening. (Paraphrasing, Reflecting, Structuring)
5. The nursing is a quick reference for current information about the client and his or her care.
(checklist, Kardex, plan)
6. charting follows a data, action, response (DAR) model to reflect the steps in the nursing process. (Exception, Flow, Focus)
Activity B: Mark each statement as either T (True) or F (False). Correct any false statements.
1. T F Health teaching promotes the client’s ability to meet his or her health needs independently.
2. T F People belonging to Generation X are technologically literate, having grown up with computers.
3. T F Therapeutic verbal communication involves the use of words alone to accomplish a particular objective.
4. T F Silence is a form of therapeutic communication that encourages the client to participate in verbal discussions.
5. T F Pie charting is a method of recording the client’s progress under the headings of patient, implementation, and education.
6. T F A change-of-shift report is discussion between a nurse from a shift that is ending and personnel coming on duty.
Activity C: Write the correct term for each description below.
1. Learning style in which a person processes information by listening or reading facts and descriptions
2. Science of teaching children or those with cognitive ability comparable to that of children
U N I T 3
End of Unit Exercises
for Chapters 7, 8, and 9
126
U N I T 3 ● End of Unit Exercises for Chapters 7, 8, and 9 127 3. Nursing role that involves assigning a task, checking on completion of that task, and evaluating the resulting
outcome
4. Person who performs health-related activities that a sick person cannot perform independently
5. Written collections of information about a person’s health, the care provided by health practitioners, and the client’s progress
6. Method of documentation that involves writing information about the client and his or her care in chronologic order
Activity D: 1.Match the terms in Column A with their explanations in Column B.
Column A
1. Psychomotor domain
2. Androgogy
3. Gerogogy
4. Functionally illiterate
2.Match the phases of the nurse–client relationship in Column A with the descriptions of what happens during those phases in Column B.
Column A
1. Introductory phase
2. Working phase
3. Terminating phase
Activity E: 1.Differentiate between informal and formal teaching based on the criteria given below.
Informal Teaching Formal Teaching
Definition
Requirements
Disadvantages
2.Differentiate between source-oriented records and problem-oriented records based on the criteria given below.
Source-Oriented Records Problem-Oriented Records Definition
Components
Column B
A. The principle of teaching adult learners
B. A style of processing that focuses on learning by doing C. Term given to a person who possesses minimal literacy
skills
D. A technique that enhances learning in older adults
Column B
A. The nurse and client plan and enact the client’s care.
B. The nurse and client mutually agree that the client’s immediate health problems have improved.
C. The client identifies one or more health problems for which he or she is seeking help.
128 U N I T 3 ● Fostering Communication
Activity F: Consider the following figures.
1.
a. Identify what is happening in the figure shown above.
b. What learning style might this client prefer?
2.
a. Identify what is happening in the figure shown above.
b. What are its benefits?
Activity G: Limited hospitalization time demands that nurses begin teaching as soon as possible after admission rather than waiting until discharge. Early attention to the client’s educational needs is essential because learning takes place in four progressive stages. Write down in the boxes below the correct sequence of the progressive stages of learning:
1. Applying new learning independently
2. Recalling and describing information to others
3. Recognizing what is being taught
4. Explaining and applying received information
Activity H: Answer the following questions.
1. What subject areas should the nurse focus on when teaching a client?
2. How can the nurse implement effective teaching?
3. How does task-related touch differ from affective touch?
4. What factors affect the ability to communicate by speech or in writing?
5. What are the seven uses of medical records?
6. What are the steps for converting traditional time into military time?
SECTION II: APPLYING YOUR KNOWLEDGE
Activity I: Give rationales for the following questions.
1. Why should the nurse select black print on white paper when providing instructions to a visually impaired client?
2. Why should the nurse document information he or she has taught and evidence demonstrating the client’s understanding?
U N I T 3 ● End of Unit Exercises for Chapters 7, 8, and 9 129
130 U N I T 3 ● Fostering Communication
3. Why is the nurse–client relationship called a therapeutic relationship?
4. Why is it important for nurses to follow their agency’s documentation policy?
5. Why do some health care agencies use military time instead of traditional time?
Activity J: Answer the following questions, focusing on nursing roles and responsibilities.
1. A nurse at an extended-care facility is caring for a client with impaired hearing who has undergone knee surgery.
How might the nurse approach teaching this client?
2. A nurse at a dermatology clinic is caring for a 12-year-old boy who has just had a cyst removed from the soft tissue on his forearm.
a. What important first step should the nurse follow after the surgical procedure?
b. Describe skin care techniques that the nurse should explain to this client?
3. A young male client is bedridden with limited use of his arms following a motorcycle accident. A female nurse needs to assist this client with activities of daily living, such as bathing and shaving.
a. What actions can the nurse take to prevent the client from misinterpreting physical nearness and hands-on nursing procedures as sexual advances?
b. Why should nurses use affective touch cautiously?
4. A nurse caring for multiple clients in a health care facility has completed shift duties and is preparing to leave for the day.
a. How should the nurse proceed when completing a shift and preparing to leave the facility?
b. What actions should the nurse receiving the shift report take to ensure maximum efficiency during this process?
5. A physician returns a nurse’s call about a change in a client’s health condition.
a. What actions should the nurse take when answering the telephone and reporting information about the client’s condition?
b. What information should the nurse document following communication with the physician?
Activity K: Think over the following questions. Discuss them with your instructor or peers.
1. A nurse is caring for three clients in a health care facility:
• A functionally illiterate elderly man who has undergone cataract surgery
• A 58-year-old woman with diabetes who has undergone hand amputation
• An 18-year-old Asian American girl who cannot speak English and has to learn how to use a hearing aid a. How can the nurse determine each client’s preferred learning style and developmental level?
b. How should the nurse provide teaching to these clients?
c. What kind of processes or techniques should the nurse follow?
2. A nurse is caring for a middle-aged client who has been diagnosed with cancer. The client is worried about the expenses involved in treatment, his future, and his dependent family members.
a. How can the nurse begin to build a therapeutic relationship with this client?
b. What communication techniques should the nurse use with this client?
3. A nurse is working at a health care facility that has a computer terminal at every client’s bedside. The nurse is required to use computerized charting for each client.
a. What actions should the nurse take when completing computerized charting?
b. What are the advantages and disadvantages of this documentation system?
SECTION III: GETTING READY FOR NCLEX
Activity L: Answer the following questions.
1. Which of the following methods should the nurse use when teaching a client who uses prescription eyeglasses?
a. Provide pamphlets in 12- to 16-point type and serif lettering.
b. Provide teaching material printed on glossy paper.
c. Ensure that the room is well lit by a ceiling light.
d. Stand in front of a window letting in bright sunlight.
2. Which of the following are characteristics of pedagogic learners? Select all that apply.
a. Need direction and supervision b. Need immediate feedback
U N I T 3 ● End of Unit Exercises for Chapters 7, 8, and 9 131
132 U N I T 3 ● Fostering Communication
c. Think abstractly d. Learn analytically e. Respond to competition
3. A nurse is caring for an elderly client who lives alone and is recovering from a fall. The client is in severe pain and angry because she believes that the fall could have been avoided if she had somebody to care for her at home.
Which of the following responses by the nurse is most appropriate when caring for this client?
a. Ask the client why she is staying alone.
b. Allow the client to express her emotions.
c. Ask the client to stop complaining.
d. Tell the client to stay calm and take her medication.
4. A nurse is teaching an American-born client about a medication regimen. What is the appropriate distance that the nurse should maintain from the client during teaching?
a. 12 or more feet b. 4 to 12 feet c. 6 inches to 4 feet d. 6 inches or less
5. A nurse is caring for a client undergoing treatment following a stroke. The nurse needs to document routine care provided, such as bathing and oral hygiene. Which of the following forms should the nurse use to document this routine nursing care?
a. Kardex b. Flow sheet c. Care plan d. Checklist
6. A nurse is caring for a client who cannot have any food or fluids orally for 4 hours before scheduled surgery.
Which of the following abbreviations should the nurse note on the client’s chart?
a. AMA b. NKA c. NPO d. NSS
Performing Basic Client Care
10 Asepsis
11 Admission, Discharge, Transfer, and Referrals 12 Vital Signs
13 Physical Assessment
14 Special Examinations and Tests
U N I T 4
134
10
Chapter Asepsis
W O R D S T O K N O W
aerobic bacteria anaerobic bacteria antimicrobial agents antiseptics
asepsis
aseptic techniques biologic defense
mechanisms chain of infection communicable diseases community-acquired
infections
concurrent disinfection contagious diseases disinfectants exit route hand antisepsis handwashing medical asepsis