Question 1
The nurse is providing care for a patient who is unhappy with the health care provider’s care.
The patient signs the Against Medical Advice (AMA) form and leaves the hospital against
medical advice. What should the nurse include in the documentation of this event in the
patient’s...
the nurse is providing care for a patient who is unhappy with the health care provider’s care
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Exam
,
,Question 1
The nurse is providing care for a patient who is unhappy with the health care provider’s care.
The patient signs the Against Medical Advice (AMA) form and leaves the hospital against
medical advice. What should the nurse include in the documentation of this event in the
patient’s medical record or on the AMA form?
1. Documentation that the patient was informed that he or she cannot come back to the
hospital
2. Documentation that the patient was informed that he or she was leaving against medical
advice
3. Documentation that the risks of leaving against medical advice were explained to the
patient
4. Documentation of any discharge instructions given to the patient
5. Documentation indicating an incident report has been completed
Correct Answer: 2,3,4
Rationale 1: It should be clearly documented that the patient was advised and understands
that he or she can come back.
Rationale 2: It should be clearly documented in the patient’s record and on the AMA form
that the patient was advised that he or she was leaving against medical advice.
Rationale 3: It should be clearly documented that the patient understands the risks of leaving
against medical advice.
Rationale 4: The AMA form includes the name of the person accompanying the patient and
any discharge instructions given.
Rationale 5: Facility policy may require that an incident report be completed, but it must not
be referenced in the chart. The patient’s record is a legal document, so the nurse should
never document that he or she filed an incident report.
Question 2
A nurse documents this statement in a patient’s medical record: “2/25/–, 2235. At 2015
patient awoke suddenly and complained of shortness of air. Pulse oximetry reading was 82%
on room air and audible wheezes could be heard.” This documentation meets which
documentation guidelines?
1. Documentation is timely
2. Documentation is concise
, 3. Documentation is objective
4. Documentation includes date and time of entry
5. Documentation is complete and accurate
Correct Answer: 2,3,4,5
Rationale 1: The nurse should document as soon as possible after an observation is made or
care is provided. The entry was made in the patient’s medical record at least 2 hours after the
patient complaint and should be labeled late entry.
Rationale 2: This entry describes the situation fully but is concise.
Rationale 3: The nurse describes factual events that can be seen, heard, smelled, or touched.
It is important to be objective and avoid vague statements that are subjective.
Rationale 4: Both the date and the time of the entry are documented.
Rationale 5: The nurse should document only facts: what he or she can see, hear, and do.
Question 3
A nurse documents the following in a patient’s medical record: “2/1/ , 1500. Patient
appears weak and faint. Patient’s skin is moist and cool, vomited bright red blood with clots.
Health care provider notified and order received to give 2 u of packed red blood cells if stat
Hgb is < 8.0. Pain medication will be given.” This documentation meets which documentation
principle?
1. Document objectively.
2. Do not document procedures in advance.
3. Use approved abbreviations.
4. Document changes in patient condition.
Correct Answer: 4
Rationale 1: Documentation should be objective and avoid vague statements that are
subjective. Only factual occurrences that can be seen, heard, smelled, or touched should be
described. The use of the word “appears” is subjective and could be manipulated later should
the treatment or judgment be challenged.
Rationale 2: The nurse has documented that pain medication will be given. This is
documenting in advance.
Rationale 3: The Joint Commission has designated the inappropriateness of “u” as an
abbreviation. “U” should be written out as “unit(s).” If unsure whether the abbreviation is
correct, the nurse should spell out the word; “<” can be misinterpreted, so it should be
spelled out as “less than.”
Rationale 4: In general, employers as well as state, federal, and professional standards
require documentation to include initial and ongoing assessments, any change in the
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