Chapter 1: Nursing Theory & Professional Practice Study Guide Maslow’s Hierarchy
Exam
History 1 : In 1860, Florence Nightingale’s Notes on Nursing raised the profile of nursing with critical thinking and respect for patient needs and rights. Nightingale
of Nursing
of Needs
is considered the founder of modern nursing and is known for her care of the sick in the Crimean War. Her contributions influenced developments in the field of epidemiology
by connecting poor sanitation with cholera and dysentery. Her role in nursing included establishing nursing as a respected profession for women that was distinct from the
medical profession. She founded a nursing school and stressed the need for university-based and continuing education for nurses.
Holistic (physical, mental, emotional, spiritual, and social). Metaparadigm: set of concepts that provide broad conceptual procedures of a discipline of human beings,
environment, health, nursing role.
Primary Roles and Functions of the Nurse
Care Provider: The nurse’s primary professional responsibility is to people
requiring nursing care”. Through education, the nurse acquires critical thinking
skills to determine the necessary course of action, psychomotor skills to
perform the necessary interventions, interpersonal skills to communicate
effectively with the patient and family, and ethical and legal skills to function
within the scope of practice and in accordance with the profession’s code of
ethics. The nurse uses critical thinking skills and clinical decision-making skills that develop through experience to make
sound clinical judgments.
Educator: nurse ensures that patients receive sufficient information and teaching on which to base consent for care and
related treatment. The nurse assesses learning needs, plans to meet those needs through specific teaching strategies, and
evaluates the effectiveness of patient teaching. Patients need to be informed about their medications, procedures, and health
promotion measures. Education becomes a major focus of discharge planning so that patients will be prepared to handle their
own needs at home.
Advocate: As the patient’s advocate, the nurse interprets information and provides necessary education. The nurse then
accepts and respects the patient’s decisions even if they are different from the nurse’s own beliefs. The nurse supports the
patient’s rights as well as wishes and communicates them to other health care providers. It is up to the nurse to be an
advocate for patients, especially in situations in which they cannot speak for themselves, such as during a severe illness or
under general anesthesia.
Leader: A leader provides direction and purpose to others, builds a sense of commitment toward common goals,
communicates effectively, and assists with addressing challenges that arise in caring for patients in a health care setting.
Change Agent : requires knowledge of change theory, which encourages change and provides strategies for effecting change.
In this role, the nurse works with patients to address their health concerns and with staff members to address change in an
organization or within a community. This role can be extended to bringing about change in the legislation on health policy
issues.
Manager: A nurse manages all of the activities and treatments for patients in reasonable timing. Promoting, restoring, and
maintaining the patient’s health requires coordinating all of the health care providers’ services.
Researcher: Nurses critique research studies and apply research to practice. Nurses determine care concerns and ask
questions about nursing practices. Nursing problems that are identified become the basis of research. By incorporating
research into their practice, nurses are involved in evidence-based practice (EBP)
Collaborator : process by which two or more people work together toward a common goal. In nursing, interprofessional
collaboration occurs when RNs, UAP, LPNs, or licensed vocational nurses (LVNs), PCPs, medical specialists, social workers,
clergy, and therapists all interact productively to provide high-quality patient care.
Delegator: In the process of collaboration, the nurse delegates certain activities to other health care personnel. Delegation is the
process of entrusting or transferring the responsibility for certain tasks to other personnel, including UAP, LVNs, and LPNs.
,Criteria for Nursing Profession
Altruism: Practitioners’ motivation is public service over personal gain . Nurses recognize nursing as their life’s work, being
an important component of their lives and clearly defining who they are. Nurses focus on service to their patients and the
community.
Body of Knowledge and Research: There is a well-defined, specific, and unique body of theoretical knowledge in nursing, leading
to defined skills, abilities, and norms, that is enlarged by research. A profession is distinguished by a specific culture with norms and
values common to its members. To advance knowledge in their field, professionals publish and communicate their knowledge. A
profession develops, evaluates, and uses theory as a basis for practice. Nursing has been based on theory since the days of
Nightingale. Numerous models for nursing practice have been developed. Nursing’s reliance on research for practice is considered
EBP.
Accountability: Nursing requires accountability, which involves accepting responsibility for actions and omissions.
Accountability has legal, ethical, and professional implications. It is essential for developing trusting relationships with patients and
co-workers. Accountability is necessary for safe patient care. Assessing for and attending to adverse reactions to treatment
requires a nurse to be accountable for actions taken.
Higher Education: Professions have specific educational requirements. Usually, professionals are educated in institutions of higher
learning. A profession requires that its members have an extended education as well as a basic liberal foundation. Higher education
provides the basis for practice and allows for lifelong educational opportunities, such as earning a master’s or doctoral degree
with its associated advantages of professional development.
Autonomy: Members of a profession have autonomy in decision-making and practice and are self-regulating in that they
develop their own policies in collaboration with one another. Nursing professionals make independent decisions within their
scope of practice and are responsible for the results and consequences of those decisions.
Code of Ethics: Professions have codes of ethics to guide decisions for practice and conduct. Ethics is the standards of right
and wrong behavior, or moral principles that guide a person’s behavior. The ICN and the ANA each have developed a code of
ethics for nurses.
Professional Organization: Numerous organizations have evolved to support and encourage high standards in nursing. Members
participate in these organizations, which aim to support and advance nursing. Each organization participates in determining
responsibilities and standards of conduct for individual members and the group and in regulating its members’ adherence to
its own professional standards. The ANA is an example of a professional organization that provides standards of professional
nursing practice.
Licensure: A profession is committed to competence and has a legally recognized license.
Diversity: Nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity, and to be
treated with respect. Nursing care is respectful of and unrestricted by considerations of age, colour, creed, culture, disability or
illness, gender, sexual orientation, nationality, politics, race, or social status. Diversity includes developmental aspects,
morphologic aspects (body frame size/obesity), culture, religion, and ethnicity. In providing care, the nurse promotes an environment
in which the human rights, values, customs, and spiritual beliefs of the individual, family, and community are respected. To respect
the diversity of patients, nurses practice culturally competent care
Code of Ethics are:
Accountability, Advocacy, Autonomy (be independent, and self-motivated), Beneficence (act in best interest of the patient),
Confidentiality, Fidelity (keep promises) Justice (relate to others with fairness and kindness) , Non-Maleficence( Do NOT
harm), Responsibility, Veracity (Be Truthful)
Practice Guidelines: The profession of nursing is guided by standards of practice and nurse practice acts. The Standards of
Professional Nursing Practice published by the ANA help ensure quality care and serve as legal criteria for adequate patient
care. ANA standards have two parts. The first part, the standards of practice, includes 6 responsibilities for the nursing
process: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation Nurses providing direct
patient care continuously follow these standards as they utilize the nursing processs
,The second part focuses on standards of professional performance, which includes ethics, advocacy, respectful and equitable
practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice
evaluation, resource stewardship, and environmental health.
Nurse practice acts provide the scope of practice defined by each state or jurisdiction and set forth the legal limits of nursing
practice. These acts are laws that the nurse must be familiar with to function in practice. It devises a decision-making tool for
nurses to help determine interventions and activities that can be performed safely by different nursing associations.
Cultural competence is a method of bringing interprofessional health care providers together to discuss health concerns
whereby cultural differences enhance, rather than hinder, the conversation through a respectful atmosphere responsive to the
health beliefs, practices, and cultural and linguistic needs of diverse patients. It is also providing culturally sensitive nursing
care to patients.
Nurse Shortage With the changing demographics of an increasing elderly population and the aging nursing workforce, the
total number of new nurses needed continues to grow. Lack of nursing teaching faculty.
Grand Theory: Global concepts from broad nursing perspectives Middle-Range Theory: limited variables and are focused
to a specific condition or population.
Non-Nursing Theories
Maslow’s Hierarchy of Needs: Maslow’s hierarchy of needs specifies the psychological and physiologic factors that affect each
person’s physical and mental health . The nurse’s understanding of these factors helps with identifying nursing diagnoses that
address the patient’s needs and values. Needs at the lower levels of the pyramid-shaped hierarchy must be met before needs at higher
levels are addressed. At the base of the pyramid are physiologic needs, including oxygen, food, elimination, temperature control, sex,
movement, rest, and comfort. These are followed by safety and security, love and belonging, self-esteem, and self-actualization. This
hierarchy allows nurses to plan the care of patients by addressing their needs on the basis of priorities.
Erikson’s Psychosocial Theory: Erikson’s (1968) Psychosocial Theory of Development and Socialization is based on individuals
interacting and learning about their world. Nurses use concepts of developmental theory to care for their patients at various stages
in life. Because nurses strive to meet the holistic needs of patients, they must address the developmental issues.
Lewin’s Change Theory: Nurses function as change agents in their leadership roles and, therefore, need to understand change
theory. According to Lewin’s (1951) Change Theory, change is a three-step process. Unfreezing, the first step, is overcoming
inertia and changing the mindset, which involves bypassing the defenses. During unfreezing, the right environment is created
for change. The second step, moving or change, is the time of transition and confusion when change takes place. Change is
supported and implementation of the change occurs. The third step is refreezing, during which the change is completed,
reinforced, and accepted. Change theory recognizes the dynamic nature of change and the need to constantly evaluate
nursing practice. First, the nurse needs to recognize when change is needed. Next, the nurse analyzes the situation to determine what
is maintaining the situation and what is working to change it. Then, the nurse identifies methods to use in the change process and
analyzes the influence of those involved in the change.
Paul’s Critical Thinking Theory: Critical thinking, according to Paul (1993), is an “intellectually disciplined process of actively
and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by,
observation, experience, reflection, reasoning, or communication, as a guide to belief and action”. In applying Paul’s
definition, nurses analyze data, generate a patient care plan, implement a plan of action for the patient, and evaluate the plan
of care. Certain intellectual values are recognized as pertinent to any subject matter, such as clarity, accuracy, precision, consistency,
relevance, sound evidence, good reasons, depth, and fairness (Paul, 1993). Nursing expands on this process of critical thinking and
adapts it to the care of the patient.
Rosenstock’s Health Belief Model: Rosenstock (1974) developed the psychological Health Belief Model. Originally, the model
was designed to predict responses of patients to treatment. Recently, however, the model has been used to predict more general
health behaviors. The model addresses possible reasons for why a patient may not comply with recommended health
promotion behaviors. This model is especially useful to nurses as they educate patients.
Review Questions
,1. The nurse supports a patient’s decision to decline more cancer treatment and to be cared for by a hospice team, even
though the nurse personally thinks the patient should seek more treatment. The nurse is practicing which nursing role?
a. Advocacy
b. Change agent
c. Leader
d. Collaborator
2. A profession has specific characteristics. In regard to how nursing meets these characteristics, which criteria are consistent
and standardized processes? (Select all that apply.)
a. Code of ethics
b. Licensing
c. Body of knowledge
d. Educational preparation
e. Altruism
3. What specific aspect of a profession does the development of theories provide?
a. Altruism
b. Body of knowledge
c. Autonomy
d. Accountability
4. Health care workers are discussing a diverse group of patients respectfully and are being responsive to the health beliefs
and practices of these patients. What important aspect of nursing professional practice are they exhibiting?
a. Autonomy
b. Accountability
c. Cultural competence
d. Autocratic leadership
5. A nurse makes a medication error, immediately assesses the patient, and reports the error to the nurse manager and the
primary care provider (PCP). Which characteristic of a professional is the nurse demonstrating?
a. Autonomy
b. Collaboration
c. Accountability
d. Altruism
6. Which are included in the ANA Standards of Professional Nursing Practice? (Select all that apply.)
a. Standards of professional performance
b. Code of ethics
c. Standards of practice
d. Legal scope of practice
e. Licensure requirements
7. Which core competency of advanced practice registered nurse (APRN) is a nurse educator exhibiting when counseling a
student nurse on the unit in therapeutic communication techniques?
a. Leadership
b. Ethical decision-making
c. Direct clinical practice
d. Expert coaching
8. Which statements describe a component discussed in nursing theories? (Select all that apply.)
a. Optimal functioning of the patient
b. Interaction with components of the environment
c. The conceptual makeup of the administration of the hospital
d. The illness and health concept
e. Safety aspect of medication administration
9. Which factors affect the nursing shortage? (Select all that apply.)
a. Aging faculty
b. Increasing elderly population
c. Job satisfaction due to adequate number of nurses
d. Aging nursing workforce
,e. Greater autonomy for nurses
10. A nurse has performed a physical examination of the patient and reviewed the laboratory results and diagnostics on the
patient’s chart. The nurse is performing which specific nursing function?
a. Diagnosis
b. Assessment
c. Education
d. Advocacy
ATI BOOK Chapter 2: Interprofessional Team
1. A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse
caring for the client should initiate a referral to which of the following members of the interprofessional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist
2. A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the
nurse initiate a referral for a social worker? (Select all that apply.)
A. A client who has terminal cancer requests hospice care in the home.
B. A client asks about community resources available for older adults.
C. A client states, "I would like to have my child baptized before surgery."
D. A client requests an electric wheelchair for use after discharge.
E. A client states, "I do not understand how to use a nebulizer."
3. A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication
prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in
understanding the medication's effects? (Select all that apply.)
A. Provider
B. Certified nursing assistant
C. Pharmacist
D. Registered nurse
E. Respiratory therapist
4. A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should
initiate a referral with which of the following members of the interprofessional care team? (Select all that apply.)
A. Social worker
B. Certified nursing assistant
C. Occupational therapist
D. Speech-language pathologist
E. Physical therapist
5. A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they
will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAs)
can perform, which of the following client activities should the nurse include? (Select all that apply.)
1. Bathing
2. Ambulating
3. Toileting
4. Determining pain level
5. Measuring vital signs
Answer Key:
,1. A. A social worker can coordinate community services to help the client, but not specifically with self-feeding devices.
1. A certified nursing assistant can help the client with feeding but does not typically procure adaptive devices for the client.
2. A registered dietitian can help with educating the client about meeting nutritional needs, but cannot help with the client's
physical limitations.
3. CORRECT: The nurse should identify that an occupational therapist can assist clients who have physical challenges
to use adaptive devices and strategies to help with self-care activities. A certified nursing assistant can help the client
with feeding but does not typically procure adaptive devices for the client
2. A. CORRECT: The nurse should initiate a referral for a social worker to provide information and assistance in
coordinating hospice care for a client.
1. CORRECT: The nurse should initiate a referral for a social worker to provide information and assistance in
coordinating care for community resources available for clients.
2. The nurse should initiate a referral for spiritual support staff if a client requests specific religious sacraments or prayers.
1. CORRECT: The nurse should initiate a referral for a social worker to assist the client in obtaining medical
equipment for use after discharge.
2. The nurse should provide client teaching for concerns regarding the use of a nebulizer. If additional information is needed,
initiate a referral for a respiratory therapist.
3. A. CORRECT: The provider must be knowledgeable about any medication prescribed for the client, including its actions,
effects, and interactions.
1. It is not within the scope of a certified nursing assistant's duties to counsel a client about medications.
2. CORRECT: A pharmacist must be knowledgeable about any medication dispensed for the client, including its
actions, effects, and interactions.
3. CORRECT: A registered nurse must be knowledgeable about any medication administered, including its actions,
effects, and interactions.
4. Although some analgesics can cause respiratory depression, requiring assistance from a respiratory therapist, it is not within
this therapist's scope of practice to counsel the client about medications prescribed by the provider.
4. C, D. CORRECT: The nurse should identify that a speech-language pathologist and an occupational therapist can initiate
specific therapy for clients who have difficulty with feeding due to swallowing difficulties.
1. A social worker can coordinate community services to help the client, but not specifically with dysphagia.
2. A certified nursing assistant can help the client with feeding but cannot assess and treat dysphagia.
F. A physical therapist can assist clients who have motor challenges to improve abilities with self-care and work but cannot
assess and treat dysphagia.
5. A, B, C, E. CORRECT: The nurse should identify that it is within the range of function for a CNA to provide basic care to
clients, such as bathing, assisting with ambulation, assisting with toileting, and measuring and recording vital signs.
D. Determining pain level is a task that requires the assessment skills of licensed personnel (nurses). It is outside the range of
function for a CAN
Chapter 1: Nursing, Theory, and Professional Practice Study Guide Review
Match the description/definition
______ 1. Standards of right and wrong behavior
______ 2. Treating the patient’s physical, mental, emotional, spiritual, and social self
______ 3. Learning the theory and skills for the nursing role
______ 4. An occupation that requires a specialized body of knowledge and training
______ 5. Process of entrusting or transferring the responsibility for certain tasks to other personnel
______ 6. Statement about the beliefs and values of nursing in relation to a specific phenomenon, such as health
______ 7. An overarching set of concepts that provide the broad conceptual boundaries of a discipline
______ 8. Minimum set of criteria to deliver quality care
a. Delegation
b. Profession
c. Standards of practice
d. Ethics
e. Holistic
f. Socialization
g. Philosophy
h. Metaparadigm
25. The nurse is acting in the role of patient advocate. This role specifically includes
,a. motivating others toward common goals.
b. incorporating research into their practice.
c. communicating the patient’s wishes to other health care providers.
d. bringing about change in the legislation on health policy issues.
26. According to the Agency for Health care Research and Quality, low health literacy is associated with which of the
following?
a. Increased hospitalizations
b. Reduced emergency care use
c. Greater use of diagnostic procedures, such as mammography
d. Less hesitancy to receive vaccines
27. Which of the following actions indicates the act of refreezing in Lewin’s change theory?
a. A patient overcomes inertia and changes her mind set.
b. There is a time of transition and confusion when change takes place.
c. Change is completed, reinforced, and accepted.
d. The right environment is created for change.
28. Florence Nightingale’s theory focuses on which of the following?
a. Environmental adaptation
b. Interpersonal processes
c. Energy fields
d. Levels of systems
29. In reviewing the history of nursing, advances in health care and the role of nurses have been associated with which of the
following?
a. Weather disasters
b. Military conflicts
c. Women’s rights movements
d. Economic growth periods
Chapter 10: Documentation, Electronic Health Records, and Reporting → Exam 1
The Medical Record: is a document with comprehensive information about a patient’s health care encounter, as well as
demographic, administrative, and clinical data. The record serves as the major communication tool between staff members and
as a single data access point for everyone involved in the care of the patient. It is a legal document that must meet guidelines
for completeness, accuracy, factual, nonjudgmental, timeliness, accessibility, and authenticity. **Can be used for court! And
cannot be altered or obliterated in an EHR **DO NOT USE ABBREVIATIONS THAT CAN BE MISUNDERSTOOD
Paper records: can have many mistakes, and can only be viewed by one person at a time, so healthcare systems have moved on from
this way
EHR(Electronic Health Record): information from inpatient and outpatient settings from different health care settings and
facilities
CPOE (Computerized provider order entry: clinicians can enter orders on a computer directly to appropriate department
Narrative charting: is chronological notes on a shift-by-shift basis.
(flow chart, flow sheet, checklist)
Formatted charting:
PIE Notes: A PIE note is used to document problem (P), intervention
(I), and evaluation (E). For example:
,P(roblem): Acute pain in lower right quadrant of abdomen rated by postsurgical patient as 8/10.
I(ntervention): Morphine sulfate (5 mg IV) given at 0930 per order for lower right quadrant abdominal pain relief.
E(valuation) Patient reported a 3/10 pain level 20 minutes after morphine was administered.
APIE Notes: An APIE note adds assessment (A), combining subjective and objective data with the PIE format. For example:
A(ssessment): Patient holding hand over surgical site and grimacing while reporting pain at a level of 8/10 on the pain scale.
SOAP Notes: A SOAP note is used to chart the subjective data (S), objective data (O), assessment (A), and plan (P). The format
is sometimes expanded to a SOAPIE note, which includes the actual interventions (I) and an evaluation (E) of intervention
outcomes. Another form of the SOAP note is the SOAPIER note, which adds revision (R) of the plan of care as necessary to meet
the follow-up needs of the patient. Documentation is usually organized in the following way:
S(ubjective data): What do the patient and others tell you?
O(bjective data): What are the results of the physical examination, relevant vital signs, or other tests?
A(ssessment): What is the patient’s current status?
P(lan): What interventions are necessary?
I(ntervention): What treatments did the nurse provide?
E(valuation of intervention outcomes): What are the patient outcomes after each intervention?
R(evision): Does the plan stay the same? What changes are needed to the care plan?
DAR Notes A DAR note is used to chart the data (D) collected about the patient’s problems, the action (A) initiated, and the
patient’s response (R) to the actions. A DAR note may read as follows:
D(ata collected): Patient grimacing. Holding hand at abdominal
surgical site. Pulse 98. States pain at a level of 8/10.
A(ction initiated) : Given morphine sulfate 5 mg IV per order
and repositioned for comfort.
R(esponse of patient): 20 minutes after morphine is given, patient states relief with a pain level at 3/10.
A communication format specifically suggested for use in nurse–physician interactions is SBAR (i.e., situation, background,
assessment, recommendation
Hand-off reports are enhanced with patient participation. Nurses should:Teach patients to actively participate and validate
information shared, and encouraged to ask questions with staff during the bedside rounds.
Charting by exception (CBE) : documentation that only records abnormal data
Sentinel event: a safety of occurrence that effects a patient and causes death or serious injury. Can be caused by
miscommunication or error in hand off.
Use of EHRs supports development of a standardized and integrated shift report to facilitate better communication of
significant information. When documentation is completed electronically at the point of care, the potential for errors and
omitted information is decreased.
Verbal And Telephone Orders Many facilities limit verbal or telephone orders to emergency situations. The PCP can access the
EMR from a smartphone, or personal computer and enter or send orders directly to the appropriate department. This removes the
nurse or unit secretary from the ordering process and decreases the possibility of error. If a nurse must be present she must
repeat the order verbatim to confirm accuracy and enters into the EMR including the date, time, physician’s name, and RN’s
signature. Most facility policies require the physician to co-sign a verbal or telephone order within a defined period.
Incident Reports MUST USE FACTS NOT OPINIONS!!!! When an unusual and unexpected event involving a patient,
visitor, or staff member occurs, an incident report is completed. An incident may be the occurrence of a fall, a medication
error, or an equipment malfunction. The purpose of this report is to document the details of the incident immediately to ensure
,accuracy. Incident reports are objective, nonjudgmental, factual reports of the occurrence and its consequences. The incident
report is not part of a medical record but is considered a risk management or quality improvement document. The fact that
an incident report was completed is not recorded in the patient’s medical record; however, the details of a patient incident are
documented.
Review Questions
1. A hospital has implemented the use of electronic health records (EHRs). While learning to use this system, the nurse
realizes that EHRs may do which of the following?
a. Limit access to the patient record to one person at a time
b. Improve access to patient information at the point of care
c. Negate the use of nursing documentation
d. Increase the potential for medication errors
2. Which statement best contributes to the nurse’s documentation of assessment of patient status in the patient’s medical
chart?
a. “Patient had a good day with minimal complaints. Patient was pleasant and cooperative during morning care.”
b. “Patient complained that the nurse didn’t come quickly enough when she pressed the call button.”
c. “Patient rated pain 7/10 at 7:45 a.m. Received pain medication at 8 a.m., reporting pain 3/10 at 8:30 a.m.”
d. “Patient was grumpy today, even after administration of pain medication, a back massage, and a nap.”
3. A patient requests a copy of his medical record. What is the correct response by the nurse?
a. Inform him that his record is the property of the facility and cannot be accessed by anyone but staff.
b. Tell him that the Code for Nurses does not allow you to give him access to his records.
c. Acknowledge that he has the right to have a copy of his records, and make arrangements per facility policy.
d. Refer his request to the hospital administrator because all such requests need to go through proper channels.
4. A patient’s sister comes to visit and asks to read the patient’s medical records. What is the best response by the nurse?
a. Settle her in a chair at the nurses’ station and give her access.
b. Respond that the contents of a patient’s medical records are private and confidential.
c. Tell her she can read the medical records only if the patient sits with her.
d. Distract the sister by changing the subject and then walking away.
5. Which are reasons that accurate documentation in the medical record is important? (Select all that apply.)
a. Reimbursement for care
b. Evidence of care provided
c. Communication between health care providers
d. Nonlegal documentation of a nurse’s actions
e. Promotion of continuity of care
6. Which note is an example of the S in SBAR?
a. Patient resting; pain was rated 3/10 1 hour after receiving narcotic analgesic.
b. Patient was admitted on evening shift with a fractured right femur after a fall at home.
c. Patient’s pain was rated 8/10 before administration of narcotic pain medication.
d. Assess pain every 2 hours, continue pain medication as prescribed, and provide back rub.
7. Which attributes are important in nursing documentation? (Select all that apply.)
a. Inconsequentiality
b. Timeliness
c. Relevancy
d. Accuracy
e. Factual basis
8. When should administered medications be documented?
a. At the end of a shift when all medications have been given
b. As given to avoid the possibility of double dosing
c. After every meal to document at least three times daily
d. When the nurse has time before going on break
9. What is an advantage of the use of electronic medical records?
a. Electronic health records (EHRs) are always available to all health care team members.
, b. Documentation in the EHR is often illegible, causing medication and treatment errors.
c. Patient information from the EHR cannot be shared with other departments or facilities which protects the patient’s privacy.
d. Recording in the EHR does not require any specialized training.
10. What is a purpose of a hand-off report?
a. Ensures continuity of care and patient safety
b. Keeps the doctor informed
c. Completed when a patient is discharged to home
d. Determines patient assignments
Chapter 15: Nursing Informatics → Exam 1
Nursing informatics is a specialty area of informatics that addresses the use of health information systems to support nursing
practice. Nursing informatics integrates nursing, computer, and information science for the management and communication
of data, information, knowledge, and wisdom.
Data Collection: As a nurse assesses a patient, data are collected and organized as a source of information. The
computerization of nursing practice data enables capture, storage, retrieval, organization, processing, and analysis of
information. The information can be used to make a diagnosis, prioritize, develop a plan for care, provide nursing decision
support, enhance documentation, and identify nursing care trends and costs. Systems that support data collection at the point of
care can directly enhance patient care by reducing the potential for errors and supporting improved assessment and data
communication. Computers, tablets, or pocket devices used at the bedside for documentation are examples of point-of-care
technology. Patient data collected by a nurse and recorded electronically are immediately available to all members of the
interprofessional health care team.
Safe Practice Alert: Nurses must ensure the accuracy of recorded data. Documentation should occur on a timely basis.
Bedside and mobile computers enable real-time charting. Workstations on wheels( WOWs) can be used at the workstation
Data, Information, Knowledge, and Wisdom: Data are facts, observations, and measurements that can be used as a basis for
reasoning, discussion, or calculation.
Telehealth or telemedicine, is the use of the Internet to link medical experts with other clinicians or patients, allowing remote
consultations with clear video images and high-fidelity links. Telehealth nursing, sometimes known as telenursing, is the
transmission by a nurse of electronic data, images, or audio from a patient’s bedside or home to other health care providers
for the purpose of providing care and improving outcomes. Patients may have telehealth hardware in their homes to provide in-
home monitoring and direct reporting to their health care providers Nurses need to be able to advise their patients on how to best
utilize these connected health applications to promote wellness and manage health problems.
Patient Safety: IT can be used to increase patient safety. Errors are analyzed to develop strategies for prevention. Diagnostic
test results are available sooner to support treatment decisions and avoid redundancy in orders. When technology such as a
bar-code medication administration (BCMA) system is used as part of the process of medication administration, fewer errors are
made. After the nurse signs into the system or scans their identification (ID) badge, the nurse electronically scans the bar
codes of the patient ID, the electronic medication administration record (eMAR) and the drug to ensure that the right patient
is getting the right drug and dose at the right time . If the EHR is properly programmed, an alert signals a potential error; it
is the nurse’s responsibility to verify all information before administration.
Computerized decision support systems (DSSs), sometimes called clinical decision support systems, include safe practice
alerts and reminders that improve the quality of care. Some DSSs assist in determining a correct diagnosis and choosing an
appropriate medication. Access to needed information at the point of care supports evidence-based practice initiatives.
Computerized provider order entry (CPOE) allows orders to be directly communicated to the appropriate department—diet orders
to dietary, medication orders to the pharmacy, laboratory orders to the laboratory. Elimination of an intermediary for order
transcription decreases the potential for errors related to the ambiguity of handwritten orders and allows quicker responses by
appropriate departments.
Standardized Terminologies A standardized nursing terminology is a structured vocabulary that provides a common means
of communication among nurses. A standardized language ensures that when a nurse talks about a specific patient problem,
Exam
History 1 : In 1860, Florence Nightingale’s Notes on Nursing raised the profile of nursing with critical thinking and respect for patient needs and rights. Nightingale
of Nursing
of Needs
is considered the founder of modern nursing and is known for her care of the sick in the Crimean War. Her contributions influenced developments in the field of epidemiology
by connecting poor sanitation with cholera and dysentery. Her role in nursing included establishing nursing as a respected profession for women that was distinct from the
medical profession. She founded a nursing school and stressed the need for university-based and continuing education for nurses.
Holistic (physical, mental, emotional, spiritual, and social). Metaparadigm: set of concepts that provide broad conceptual procedures of a discipline of human beings,
environment, health, nursing role.
Primary Roles and Functions of the Nurse
Care Provider: The nurse’s primary professional responsibility is to people
requiring nursing care”. Through education, the nurse acquires critical thinking
skills to determine the necessary course of action, psychomotor skills to
perform the necessary interventions, interpersonal skills to communicate
effectively with the patient and family, and ethical and legal skills to function
within the scope of practice and in accordance with the profession’s code of
ethics. The nurse uses critical thinking skills and clinical decision-making skills that develop through experience to make
sound clinical judgments.
Educator: nurse ensures that patients receive sufficient information and teaching on which to base consent for care and
related treatment. The nurse assesses learning needs, plans to meet those needs through specific teaching strategies, and
evaluates the effectiveness of patient teaching. Patients need to be informed about their medications, procedures, and health
promotion measures. Education becomes a major focus of discharge planning so that patients will be prepared to handle their
own needs at home.
Advocate: As the patient’s advocate, the nurse interprets information and provides necessary education. The nurse then
accepts and respects the patient’s decisions even if they are different from the nurse’s own beliefs. The nurse supports the
patient’s rights as well as wishes and communicates them to other health care providers. It is up to the nurse to be an
advocate for patients, especially in situations in which they cannot speak for themselves, such as during a severe illness or
under general anesthesia.
Leader: A leader provides direction and purpose to others, builds a sense of commitment toward common goals,
communicates effectively, and assists with addressing challenges that arise in caring for patients in a health care setting.
Change Agent : requires knowledge of change theory, which encourages change and provides strategies for effecting change.
In this role, the nurse works with patients to address their health concerns and with staff members to address change in an
organization or within a community. This role can be extended to bringing about change in the legislation on health policy
issues.
Manager: A nurse manages all of the activities and treatments for patients in reasonable timing. Promoting, restoring, and
maintaining the patient’s health requires coordinating all of the health care providers’ services.
Researcher: Nurses critique research studies and apply research to practice. Nurses determine care concerns and ask
questions about nursing practices. Nursing problems that are identified become the basis of research. By incorporating
research into their practice, nurses are involved in evidence-based practice (EBP)
Collaborator : process by which two or more people work together toward a common goal. In nursing, interprofessional
collaboration occurs when RNs, UAP, LPNs, or licensed vocational nurses (LVNs), PCPs, medical specialists, social workers,
clergy, and therapists all interact productively to provide high-quality patient care.
Delegator: In the process of collaboration, the nurse delegates certain activities to other health care personnel. Delegation is the
process of entrusting or transferring the responsibility for certain tasks to other personnel, including UAP, LVNs, and LPNs.
,Criteria for Nursing Profession
Altruism: Practitioners’ motivation is public service over personal gain . Nurses recognize nursing as their life’s work, being
an important component of their lives and clearly defining who they are. Nurses focus on service to their patients and the
community.
Body of Knowledge and Research: There is a well-defined, specific, and unique body of theoretical knowledge in nursing, leading
to defined skills, abilities, and norms, that is enlarged by research. A profession is distinguished by a specific culture with norms and
values common to its members. To advance knowledge in their field, professionals publish and communicate their knowledge. A
profession develops, evaluates, and uses theory as a basis for practice. Nursing has been based on theory since the days of
Nightingale. Numerous models for nursing practice have been developed. Nursing’s reliance on research for practice is considered
EBP.
Accountability: Nursing requires accountability, which involves accepting responsibility for actions and omissions.
Accountability has legal, ethical, and professional implications. It is essential for developing trusting relationships with patients and
co-workers. Accountability is necessary for safe patient care. Assessing for and attending to adverse reactions to treatment
requires a nurse to be accountable for actions taken.
Higher Education: Professions have specific educational requirements. Usually, professionals are educated in institutions of higher
learning. A profession requires that its members have an extended education as well as a basic liberal foundation. Higher education
provides the basis for practice and allows for lifelong educational opportunities, such as earning a master’s or doctoral degree
with its associated advantages of professional development.
Autonomy: Members of a profession have autonomy in decision-making and practice and are self-regulating in that they
develop their own policies in collaboration with one another. Nursing professionals make independent decisions within their
scope of practice and are responsible for the results and consequences of those decisions.
Code of Ethics: Professions have codes of ethics to guide decisions for practice and conduct. Ethics is the standards of right
and wrong behavior, or moral principles that guide a person’s behavior. The ICN and the ANA each have developed a code of
ethics for nurses.
Professional Organization: Numerous organizations have evolved to support and encourage high standards in nursing. Members
participate in these organizations, which aim to support and advance nursing. Each organization participates in determining
responsibilities and standards of conduct for individual members and the group and in regulating its members’ adherence to
its own professional standards. The ANA is an example of a professional organization that provides standards of professional
nursing practice.
Licensure: A profession is committed to competence and has a legally recognized license.
Diversity: Nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity, and to be
treated with respect. Nursing care is respectful of and unrestricted by considerations of age, colour, creed, culture, disability or
illness, gender, sexual orientation, nationality, politics, race, or social status. Diversity includes developmental aspects,
morphologic aspects (body frame size/obesity), culture, religion, and ethnicity. In providing care, the nurse promotes an environment
in which the human rights, values, customs, and spiritual beliefs of the individual, family, and community are respected. To respect
the diversity of patients, nurses practice culturally competent care
Code of Ethics are:
Accountability, Advocacy, Autonomy (be independent, and self-motivated), Beneficence (act in best interest of the patient),
Confidentiality, Fidelity (keep promises) Justice (relate to others with fairness and kindness) , Non-Maleficence( Do NOT
harm), Responsibility, Veracity (Be Truthful)
Practice Guidelines: The profession of nursing is guided by standards of practice and nurse practice acts. The Standards of
Professional Nursing Practice published by the ANA help ensure quality care and serve as legal criteria for adequate patient
care. ANA standards have two parts. The first part, the standards of practice, includes 6 responsibilities for the nursing
process: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation Nurses providing direct
patient care continuously follow these standards as they utilize the nursing processs
,The second part focuses on standards of professional performance, which includes ethics, advocacy, respectful and equitable
practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice
evaluation, resource stewardship, and environmental health.
Nurse practice acts provide the scope of practice defined by each state or jurisdiction and set forth the legal limits of nursing
practice. These acts are laws that the nurse must be familiar with to function in practice. It devises a decision-making tool for
nurses to help determine interventions and activities that can be performed safely by different nursing associations.
Cultural competence is a method of bringing interprofessional health care providers together to discuss health concerns
whereby cultural differences enhance, rather than hinder, the conversation through a respectful atmosphere responsive to the
health beliefs, practices, and cultural and linguistic needs of diverse patients. It is also providing culturally sensitive nursing
care to patients.
Nurse Shortage With the changing demographics of an increasing elderly population and the aging nursing workforce, the
total number of new nurses needed continues to grow. Lack of nursing teaching faculty.
Grand Theory: Global concepts from broad nursing perspectives Middle-Range Theory: limited variables and are focused
to a specific condition or population.
Non-Nursing Theories
Maslow’s Hierarchy of Needs: Maslow’s hierarchy of needs specifies the psychological and physiologic factors that affect each
person’s physical and mental health . The nurse’s understanding of these factors helps with identifying nursing diagnoses that
address the patient’s needs and values. Needs at the lower levels of the pyramid-shaped hierarchy must be met before needs at higher
levels are addressed. At the base of the pyramid are physiologic needs, including oxygen, food, elimination, temperature control, sex,
movement, rest, and comfort. These are followed by safety and security, love and belonging, self-esteem, and self-actualization. This
hierarchy allows nurses to plan the care of patients by addressing their needs on the basis of priorities.
Erikson’s Psychosocial Theory: Erikson’s (1968) Psychosocial Theory of Development and Socialization is based on individuals
interacting and learning about their world. Nurses use concepts of developmental theory to care for their patients at various stages
in life. Because nurses strive to meet the holistic needs of patients, they must address the developmental issues.
Lewin’s Change Theory: Nurses function as change agents in their leadership roles and, therefore, need to understand change
theory. According to Lewin’s (1951) Change Theory, change is a three-step process. Unfreezing, the first step, is overcoming
inertia and changing the mindset, which involves bypassing the defenses. During unfreezing, the right environment is created
for change. The second step, moving or change, is the time of transition and confusion when change takes place. Change is
supported and implementation of the change occurs. The third step is refreezing, during which the change is completed,
reinforced, and accepted. Change theory recognizes the dynamic nature of change and the need to constantly evaluate
nursing practice. First, the nurse needs to recognize when change is needed. Next, the nurse analyzes the situation to determine what
is maintaining the situation and what is working to change it. Then, the nurse identifies methods to use in the change process and
analyzes the influence of those involved in the change.
Paul’s Critical Thinking Theory: Critical thinking, according to Paul (1993), is an “intellectually disciplined process of actively
and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by,
observation, experience, reflection, reasoning, or communication, as a guide to belief and action”. In applying Paul’s
definition, nurses analyze data, generate a patient care plan, implement a plan of action for the patient, and evaluate the plan
of care. Certain intellectual values are recognized as pertinent to any subject matter, such as clarity, accuracy, precision, consistency,
relevance, sound evidence, good reasons, depth, and fairness (Paul, 1993). Nursing expands on this process of critical thinking and
adapts it to the care of the patient.
Rosenstock’s Health Belief Model: Rosenstock (1974) developed the psychological Health Belief Model. Originally, the model
was designed to predict responses of patients to treatment. Recently, however, the model has been used to predict more general
health behaviors. The model addresses possible reasons for why a patient may not comply with recommended health
promotion behaviors. This model is especially useful to nurses as they educate patients.
Review Questions
,1. The nurse supports a patient’s decision to decline more cancer treatment and to be cared for by a hospice team, even
though the nurse personally thinks the patient should seek more treatment. The nurse is practicing which nursing role?
a. Advocacy
b. Change agent
c. Leader
d. Collaborator
2. A profession has specific characteristics. In regard to how nursing meets these characteristics, which criteria are consistent
and standardized processes? (Select all that apply.)
a. Code of ethics
b. Licensing
c. Body of knowledge
d. Educational preparation
e. Altruism
3. What specific aspect of a profession does the development of theories provide?
a. Altruism
b. Body of knowledge
c. Autonomy
d. Accountability
4. Health care workers are discussing a diverse group of patients respectfully and are being responsive to the health beliefs
and practices of these patients. What important aspect of nursing professional practice are they exhibiting?
a. Autonomy
b. Accountability
c. Cultural competence
d. Autocratic leadership
5. A nurse makes a medication error, immediately assesses the patient, and reports the error to the nurse manager and the
primary care provider (PCP). Which characteristic of a professional is the nurse demonstrating?
a. Autonomy
b. Collaboration
c. Accountability
d. Altruism
6. Which are included in the ANA Standards of Professional Nursing Practice? (Select all that apply.)
a. Standards of professional performance
b. Code of ethics
c. Standards of practice
d. Legal scope of practice
e. Licensure requirements
7. Which core competency of advanced practice registered nurse (APRN) is a nurse educator exhibiting when counseling a
student nurse on the unit in therapeutic communication techniques?
a. Leadership
b. Ethical decision-making
c. Direct clinical practice
d. Expert coaching
8. Which statements describe a component discussed in nursing theories? (Select all that apply.)
a. Optimal functioning of the patient
b. Interaction with components of the environment
c. The conceptual makeup of the administration of the hospital
d. The illness and health concept
e. Safety aspect of medication administration
9. Which factors affect the nursing shortage? (Select all that apply.)
a. Aging faculty
b. Increasing elderly population
c. Job satisfaction due to adequate number of nurses
d. Aging nursing workforce
,e. Greater autonomy for nurses
10. A nurse has performed a physical examination of the patient and reviewed the laboratory results and diagnostics on the
patient’s chart. The nurse is performing which specific nursing function?
a. Diagnosis
b. Assessment
c. Education
d. Advocacy
ATI BOOK Chapter 2: Interprofessional Team
1. A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse
caring for the client should initiate a referral to which of the following members of the interprofessional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist
2. A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the
nurse initiate a referral for a social worker? (Select all that apply.)
A. A client who has terminal cancer requests hospice care in the home.
B. A client asks about community resources available for older adults.
C. A client states, "I would like to have my child baptized before surgery."
D. A client requests an electric wheelchair for use after discharge.
E. A client states, "I do not understand how to use a nebulizer."
3. A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication
prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in
understanding the medication's effects? (Select all that apply.)
A. Provider
B. Certified nursing assistant
C. Pharmacist
D. Registered nurse
E. Respiratory therapist
4. A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should
initiate a referral with which of the following members of the interprofessional care team? (Select all that apply.)
A. Social worker
B. Certified nursing assistant
C. Occupational therapist
D. Speech-language pathologist
E. Physical therapist
5. A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they
will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAs)
can perform, which of the following client activities should the nurse include? (Select all that apply.)
1. Bathing
2. Ambulating
3. Toileting
4. Determining pain level
5. Measuring vital signs
Answer Key:
,1. A. A social worker can coordinate community services to help the client, but not specifically with self-feeding devices.
1. A certified nursing assistant can help the client with feeding but does not typically procure adaptive devices for the client.
2. A registered dietitian can help with educating the client about meeting nutritional needs, but cannot help with the client's
physical limitations.
3. CORRECT: The nurse should identify that an occupational therapist can assist clients who have physical challenges
to use adaptive devices and strategies to help with self-care activities. A certified nursing assistant can help the client
with feeding but does not typically procure adaptive devices for the client
2. A. CORRECT: The nurse should initiate a referral for a social worker to provide information and assistance in
coordinating hospice care for a client.
1. CORRECT: The nurse should initiate a referral for a social worker to provide information and assistance in
coordinating care for community resources available for clients.
2. The nurse should initiate a referral for spiritual support staff if a client requests specific religious sacraments or prayers.
1. CORRECT: The nurse should initiate a referral for a social worker to assist the client in obtaining medical
equipment for use after discharge.
2. The nurse should provide client teaching for concerns regarding the use of a nebulizer. If additional information is needed,
initiate a referral for a respiratory therapist.
3. A. CORRECT: The provider must be knowledgeable about any medication prescribed for the client, including its actions,
effects, and interactions.
1. It is not within the scope of a certified nursing assistant's duties to counsel a client about medications.
2. CORRECT: A pharmacist must be knowledgeable about any medication dispensed for the client, including its
actions, effects, and interactions.
3. CORRECT: A registered nurse must be knowledgeable about any medication administered, including its actions,
effects, and interactions.
4. Although some analgesics can cause respiratory depression, requiring assistance from a respiratory therapist, it is not within
this therapist's scope of practice to counsel the client about medications prescribed by the provider.
4. C, D. CORRECT: The nurse should identify that a speech-language pathologist and an occupational therapist can initiate
specific therapy for clients who have difficulty with feeding due to swallowing difficulties.
1. A social worker can coordinate community services to help the client, but not specifically with dysphagia.
2. A certified nursing assistant can help the client with feeding but cannot assess and treat dysphagia.
F. A physical therapist can assist clients who have motor challenges to improve abilities with self-care and work but cannot
assess and treat dysphagia.
5. A, B, C, E. CORRECT: The nurse should identify that it is within the range of function for a CNA to provide basic care to
clients, such as bathing, assisting with ambulation, assisting with toileting, and measuring and recording vital signs.
D. Determining pain level is a task that requires the assessment skills of licensed personnel (nurses). It is outside the range of
function for a CAN
Chapter 1: Nursing, Theory, and Professional Practice Study Guide Review
Match the description/definition
______ 1. Standards of right and wrong behavior
______ 2. Treating the patient’s physical, mental, emotional, spiritual, and social self
______ 3. Learning the theory and skills for the nursing role
______ 4. An occupation that requires a specialized body of knowledge and training
______ 5. Process of entrusting or transferring the responsibility for certain tasks to other personnel
______ 6. Statement about the beliefs and values of nursing in relation to a specific phenomenon, such as health
______ 7. An overarching set of concepts that provide the broad conceptual boundaries of a discipline
______ 8. Minimum set of criteria to deliver quality care
a. Delegation
b. Profession
c. Standards of practice
d. Ethics
e. Holistic
f. Socialization
g. Philosophy
h. Metaparadigm
25. The nurse is acting in the role of patient advocate. This role specifically includes
,a. motivating others toward common goals.
b. incorporating research into their practice.
c. communicating the patient’s wishes to other health care providers.
d. bringing about change in the legislation on health policy issues.
26. According to the Agency for Health care Research and Quality, low health literacy is associated with which of the
following?
a. Increased hospitalizations
b. Reduced emergency care use
c. Greater use of diagnostic procedures, such as mammography
d. Less hesitancy to receive vaccines
27. Which of the following actions indicates the act of refreezing in Lewin’s change theory?
a. A patient overcomes inertia and changes her mind set.
b. There is a time of transition and confusion when change takes place.
c. Change is completed, reinforced, and accepted.
d. The right environment is created for change.
28. Florence Nightingale’s theory focuses on which of the following?
a. Environmental adaptation
b. Interpersonal processes
c. Energy fields
d. Levels of systems
29. In reviewing the history of nursing, advances in health care and the role of nurses have been associated with which of the
following?
a. Weather disasters
b. Military conflicts
c. Women’s rights movements
d. Economic growth periods
Chapter 10: Documentation, Electronic Health Records, and Reporting → Exam 1
The Medical Record: is a document with comprehensive information about a patient’s health care encounter, as well as
demographic, administrative, and clinical data. The record serves as the major communication tool between staff members and
as a single data access point for everyone involved in the care of the patient. It is a legal document that must meet guidelines
for completeness, accuracy, factual, nonjudgmental, timeliness, accessibility, and authenticity. **Can be used for court! And
cannot be altered or obliterated in an EHR **DO NOT USE ABBREVIATIONS THAT CAN BE MISUNDERSTOOD
Paper records: can have many mistakes, and can only be viewed by one person at a time, so healthcare systems have moved on from
this way
EHR(Electronic Health Record): information from inpatient and outpatient settings from different health care settings and
facilities
CPOE (Computerized provider order entry: clinicians can enter orders on a computer directly to appropriate department
Narrative charting: is chronological notes on a shift-by-shift basis.
(flow chart, flow sheet, checklist)
Formatted charting:
PIE Notes: A PIE note is used to document problem (P), intervention
(I), and evaluation (E). For example:
,P(roblem): Acute pain in lower right quadrant of abdomen rated by postsurgical patient as 8/10.
I(ntervention): Morphine sulfate (5 mg IV) given at 0930 per order for lower right quadrant abdominal pain relief.
E(valuation) Patient reported a 3/10 pain level 20 minutes after morphine was administered.
APIE Notes: An APIE note adds assessment (A), combining subjective and objective data with the PIE format. For example:
A(ssessment): Patient holding hand over surgical site and grimacing while reporting pain at a level of 8/10 on the pain scale.
SOAP Notes: A SOAP note is used to chart the subjective data (S), objective data (O), assessment (A), and plan (P). The format
is sometimes expanded to a SOAPIE note, which includes the actual interventions (I) and an evaluation (E) of intervention
outcomes. Another form of the SOAP note is the SOAPIER note, which adds revision (R) of the plan of care as necessary to meet
the follow-up needs of the patient. Documentation is usually organized in the following way:
S(ubjective data): What do the patient and others tell you?
O(bjective data): What are the results of the physical examination, relevant vital signs, or other tests?
A(ssessment): What is the patient’s current status?
P(lan): What interventions are necessary?
I(ntervention): What treatments did the nurse provide?
E(valuation of intervention outcomes): What are the patient outcomes after each intervention?
R(evision): Does the plan stay the same? What changes are needed to the care plan?
DAR Notes A DAR note is used to chart the data (D) collected about the patient’s problems, the action (A) initiated, and the
patient’s response (R) to the actions. A DAR note may read as follows:
D(ata collected): Patient grimacing. Holding hand at abdominal
surgical site. Pulse 98. States pain at a level of 8/10.
A(ction initiated) : Given morphine sulfate 5 mg IV per order
and repositioned for comfort.
R(esponse of patient): 20 minutes after morphine is given, patient states relief with a pain level at 3/10.
A communication format specifically suggested for use in nurse–physician interactions is SBAR (i.e., situation, background,
assessment, recommendation
Hand-off reports are enhanced with patient participation. Nurses should:Teach patients to actively participate and validate
information shared, and encouraged to ask questions with staff during the bedside rounds.
Charting by exception (CBE) : documentation that only records abnormal data
Sentinel event: a safety of occurrence that effects a patient and causes death or serious injury. Can be caused by
miscommunication or error in hand off.
Use of EHRs supports development of a standardized and integrated shift report to facilitate better communication of
significant information. When documentation is completed electronically at the point of care, the potential for errors and
omitted information is decreased.
Verbal And Telephone Orders Many facilities limit verbal or telephone orders to emergency situations. The PCP can access the
EMR from a smartphone, or personal computer and enter or send orders directly to the appropriate department. This removes the
nurse or unit secretary from the ordering process and decreases the possibility of error. If a nurse must be present she must
repeat the order verbatim to confirm accuracy and enters into the EMR including the date, time, physician’s name, and RN’s
signature. Most facility policies require the physician to co-sign a verbal or telephone order within a defined period.
Incident Reports MUST USE FACTS NOT OPINIONS!!!! When an unusual and unexpected event involving a patient,
visitor, or staff member occurs, an incident report is completed. An incident may be the occurrence of a fall, a medication
error, or an equipment malfunction. The purpose of this report is to document the details of the incident immediately to ensure
,accuracy. Incident reports are objective, nonjudgmental, factual reports of the occurrence and its consequences. The incident
report is not part of a medical record but is considered a risk management or quality improvement document. The fact that
an incident report was completed is not recorded in the patient’s medical record; however, the details of a patient incident are
documented.
Review Questions
1. A hospital has implemented the use of electronic health records (EHRs). While learning to use this system, the nurse
realizes that EHRs may do which of the following?
a. Limit access to the patient record to one person at a time
b. Improve access to patient information at the point of care
c. Negate the use of nursing documentation
d. Increase the potential for medication errors
2. Which statement best contributes to the nurse’s documentation of assessment of patient status in the patient’s medical
chart?
a. “Patient had a good day with minimal complaints. Patient was pleasant and cooperative during morning care.”
b. “Patient complained that the nurse didn’t come quickly enough when she pressed the call button.”
c. “Patient rated pain 7/10 at 7:45 a.m. Received pain medication at 8 a.m., reporting pain 3/10 at 8:30 a.m.”
d. “Patient was grumpy today, even after administration of pain medication, a back massage, and a nap.”
3. A patient requests a copy of his medical record. What is the correct response by the nurse?
a. Inform him that his record is the property of the facility and cannot be accessed by anyone but staff.
b. Tell him that the Code for Nurses does not allow you to give him access to his records.
c. Acknowledge that he has the right to have a copy of his records, and make arrangements per facility policy.
d. Refer his request to the hospital administrator because all such requests need to go through proper channels.
4. A patient’s sister comes to visit and asks to read the patient’s medical records. What is the best response by the nurse?
a. Settle her in a chair at the nurses’ station and give her access.
b. Respond that the contents of a patient’s medical records are private and confidential.
c. Tell her she can read the medical records only if the patient sits with her.
d. Distract the sister by changing the subject and then walking away.
5. Which are reasons that accurate documentation in the medical record is important? (Select all that apply.)
a. Reimbursement for care
b. Evidence of care provided
c. Communication between health care providers
d. Nonlegal documentation of a nurse’s actions
e. Promotion of continuity of care
6. Which note is an example of the S in SBAR?
a. Patient resting; pain was rated 3/10 1 hour after receiving narcotic analgesic.
b. Patient was admitted on evening shift with a fractured right femur after a fall at home.
c. Patient’s pain was rated 8/10 before administration of narcotic pain medication.
d. Assess pain every 2 hours, continue pain medication as prescribed, and provide back rub.
7. Which attributes are important in nursing documentation? (Select all that apply.)
a. Inconsequentiality
b. Timeliness
c. Relevancy
d. Accuracy
e. Factual basis
8. When should administered medications be documented?
a. At the end of a shift when all medications have been given
b. As given to avoid the possibility of double dosing
c. After every meal to document at least three times daily
d. When the nurse has time before going on break
9. What is an advantage of the use of electronic medical records?
a. Electronic health records (EHRs) are always available to all health care team members.
, b. Documentation in the EHR is often illegible, causing medication and treatment errors.
c. Patient information from the EHR cannot be shared with other departments or facilities which protects the patient’s privacy.
d. Recording in the EHR does not require any specialized training.
10. What is a purpose of a hand-off report?
a. Ensures continuity of care and patient safety
b. Keeps the doctor informed
c. Completed when a patient is discharged to home
d. Determines patient assignments
Chapter 15: Nursing Informatics → Exam 1
Nursing informatics is a specialty area of informatics that addresses the use of health information systems to support nursing
practice. Nursing informatics integrates nursing, computer, and information science for the management and communication
of data, information, knowledge, and wisdom.
Data Collection: As a nurse assesses a patient, data are collected and organized as a source of information. The
computerization of nursing practice data enables capture, storage, retrieval, organization, processing, and analysis of
information. The information can be used to make a diagnosis, prioritize, develop a plan for care, provide nursing decision
support, enhance documentation, and identify nursing care trends and costs. Systems that support data collection at the point of
care can directly enhance patient care by reducing the potential for errors and supporting improved assessment and data
communication. Computers, tablets, or pocket devices used at the bedside for documentation are examples of point-of-care
technology. Patient data collected by a nurse and recorded electronically are immediately available to all members of the
interprofessional health care team.
Safe Practice Alert: Nurses must ensure the accuracy of recorded data. Documentation should occur on a timely basis.
Bedside and mobile computers enable real-time charting. Workstations on wheels( WOWs) can be used at the workstation
Data, Information, Knowledge, and Wisdom: Data are facts, observations, and measurements that can be used as a basis for
reasoning, discussion, or calculation.
Telehealth or telemedicine, is the use of the Internet to link medical experts with other clinicians or patients, allowing remote
consultations with clear video images and high-fidelity links. Telehealth nursing, sometimes known as telenursing, is the
transmission by a nurse of electronic data, images, or audio from a patient’s bedside or home to other health care providers
for the purpose of providing care and improving outcomes. Patients may have telehealth hardware in their homes to provide in-
home monitoring and direct reporting to their health care providers Nurses need to be able to advise their patients on how to best
utilize these connected health applications to promote wellness and manage health problems.
Patient Safety: IT can be used to increase patient safety. Errors are analyzed to develop strategies for prevention. Diagnostic
test results are available sooner to support treatment decisions and avoid redundancy in orders. When technology such as a
bar-code medication administration (BCMA) system is used as part of the process of medication administration, fewer errors are
made. After the nurse signs into the system or scans their identification (ID) badge, the nurse electronically scans the bar
codes of the patient ID, the electronic medication administration record (eMAR) and the drug to ensure that the right patient
is getting the right drug and dose at the right time . If the EHR is properly programmed, an alert signals a potential error; it
is the nurse’s responsibility to verify all information before administration.
Computerized decision support systems (DSSs), sometimes called clinical decision support systems, include safe practice
alerts and reminders that improve the quality of care. Some DSSs assist in determining a correct diagnosis and choosing an
appropriate medication. Access to needed information at the point of care supports evidence-based practice initiatives.
Computerized provider order entry (CPOE) allows orders to be directly communicated to the appropriate department—diet orders
to dietary, medication orders to the pharmacy, laboratory orders to the laboratory. Elimination of an intermediary for order
transcription decreases the potential for errors related to the ambiguity of handwritten orders and allows quicker responses by
appropriate departments.
Standardized Terminologies A standardized nursing terminology is a structured vocabulary that provides a common means
of communication among nurses. A standardized language ensures that when a nurse talks about a specific patient problem,
