Module 15- Observation and Charting

Which of the following most completely defines observation?

Watching the activities of the patient/resident
Listening to the patient/resident and to staff reports
Reading the charts and records
Gathering patient/resident information by using the four main senses

An error made while writing in the patient’s/resident’s chart is corrected by:

Crossing out the mistake until it can no longer be read
Tearing out the sheet of paper in the chart and write on a new one
Drawing a line through the wrong entry and write an explanation of why it was an error
Drawing a single line through the entry, writing the word “error” above the line, and initial the entry

Which of the following statements is an example of objective data or information?

“Mrs. O’Hara said she felt sick to her stomach”
“Mr. Jones says he has pain in the lower part of his back”
“Mrs. O’Hara complained of feeling chilled, so I closed the window”
“Mr. Jones vomited 250cc of fluid after lunch”

Using the following statement, identify the sentence that uses the correct abbreviations: Patient/resident up in wheelchair all
afternoon. Range of motion done three times a day. Physical Therapy to ambulate patient/resident after meals every day.
Patient/resident may be out of bed as desired.

Res. in w/c all P.M. ROM TID. P.T. to amb. res. pc qd. Res. OOB ad lib.
R. up in W/C all P.M. ROM three qd. Phys.Ther. to amb. R. pc qd. R. out of bed ad lib.
Res. up in wc. qd Range of mot tid. Pt. to amb res qd Patient/resident may be oobed prn.
Res. up in wc. No c/o pain. To x-ray for UGI series

The words “ambulatory,” “bathroom privileges” and “before meals” are correctly abbreviated in only one of the sentences below.
The correct abbreviations are:

Amb., BR, and p.c.
Amb., BR, and a.c.
Amb., BRP, and a.c.
Amb., BRP and p.c.

A quick, easy, source of patient/resident information which includes the patient’s/resident’s diagnosis, diet, activity, special
treatments and routine care measures is known as a:

History and physical
Kardex file
Patient flowchart
Graphic chart

The Nurse Assistant has just given Mrs. Kennedy a complete bed bath. What type of information would be appropriate to chart?

The condition of Mrs. Kennedy’s skin and how she tolerated the bath
The fact that Mrs. Kennedy accidentally dropped the water pitcher
The fact that Mrs. Kennedy likes her toilet items kept in the overbed table
Mrs. Kennedy’s roommate talked to the Nurse Assistant throughout the entire bathing procedure

The routine, daily nursing tasks performed for a patient/resident are charted on the:

Progress sheet
Nurses notes
ADL sheet
Incident report

When charting on a patient’s/resident’s medical record, the Nurse Assistant should:

Erase any errors in charting
Always use ink
Skip a line between entries
Chart all procedures to be done

A list of the patient’s/resident’s needs and specific nursing activities to address those needs would be found

Patient’s/resident’s care plan
Patient’s/resident’s history and physical
Graphic chart
Nurse’s notes

The Minimum Data Set (MDS) manual

Gives a standardized approach to care
Gives a structure to facility care
Helps the nurse complete accurate assessments
Triggers needed assessments
All of the above

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