A nurse is preparing to complete an occurrence report for a client who fell at the facility. Which of the following actions should the nurse take?
Use objective terminology when documenting
Wait at least 12 hours to report the occurrence
Omit the name of the individuals involved
Document completion of the report in the client’s medical record
The Correct Answer is A
Choice A reason: This statement is correct because the nurse should use objective terminology when documenting the occurrence. Objective terminology means using factual, unbiased, and verifiable information, such as the date, time, location, witnesses, and events of the occurrence. The nurse should avoid using subjective, opinionated, or judgmental language, such as blaming, criticizing, or speculating about the occurrence.
Choice B reason: This statement is incorrect because the nurse should not wait at least 12 hours to report the occurrence. The nurse should report the occurrence as soon as possible, preferably within an hour of the incident. The nurse should also notify the appropriate personnel, such as the charge nurse, the provider, and the risk manager. Delaying the report may compromise the client's safety and wellbeing, and the accuracy and completeness of the documentation.
Choice C reason: This statement is incorrect because the nurse should not omit the name of the individuals involved in the occurrence. The nurse should include the name of the client, the staff, and any other relevant parties, such as family members or visitors. The nurse should also document the role and actions of each individual, and their response to the occurrence. Omitting the name of the individuals may affect the accountability and follow-up of the occurrence.
Choice D reason: This statement is incorrect because the nurse should not document completion of the report in the client’s medical record. The nurse should document the occurrence report separately from the client’s medical record, and follow the facility's policy and procedure for filing and storing the report. The nurse should also document the occurrence in the client’s medical record, but only the facts and the nursing actions, not the details or the existence of the report. Documenting completion of the report in the client’s medical record may expose the facility to legal liability or litigation.
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Related Questions
Correct Answer is A
Explanation
Choice A reason: Telephone number is an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, telephone number is one of the approved patient identifiers that can be used to reliably identify the individual as the person for whom the service or treatment is intended. Telephone number is a person specific identifier that is unlikely to be shared by another client.
Choice B reason: Room number is not an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, room number is not an example of a unique patient identifier. Room number is not a person specific identifier, but a location specific identifier that can change or be assigned to another client.
Choice C reason: Medical condition is not an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, medical condition is not an example of a unique patient identifier. Medical condition is not a person specific identifier, but a health specific identifier that can be common or vague among different clients.
Choice D reason: Home address is not an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, home address is not an example of a unique patient identifier. Home address is not a person specific identifier, but a place specific identifier that can be shared or changed by the client.
Correct Answer is D
Explanation
Choice A reason: SOAP documentation is not the correct method for documenting only unexpected findings. SOAP documentation requires the nurse to document both normal and abnormal findings, as well as the plan of care for the client.
Choice B reason: Problem oriented medical record (POMR) is not the correct method for documenting only unexpected findings. POMR is a method that organizes the documentation around the client's problems, rather than the source of data. It consists of four components: database, problem list, plan, and progress notes.
Choice C reason: Focus charting (DAR) is not the correct method for documenting only unexpected findings. Focus charting is a method that uses the nursing process and the client's perspective to document the client's care. It consists of three components: data, action, and response.
Choice D reason: Charting by exception (CBE) is the correct method for documenting only unexpected findings. CBE is a method that assumes that all standards of care are met unless otherwise documented. It allows the nurse to document only significant or abnormal findings, such as changes in the client's condition, interventions, or outcomes.
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