A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says to the nurse, "I don't want to have you draw any more blood for those useless tests." When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:
"Blood not drawn because tests are no longer desired by patient."
"Refuses to have blood drawn; says tests are 'useless. Doctor notified."
"Doctor notified of failure to draw ordered blood work."
"Refuses to have blood drawn. Doctor notified."
The Correct Answer is B
A. "Blood not drawn because tests are no longer desired by patient."
This statement is vague and lacks specific details regarding the patient's exact refusal and the communication with the doctor.
B. "Refuses to have blood drawn; says tests are 'useless.' Doctor notified."
This response documents the patient's refusal with their exact words ("useless") and also notes that the doctor has been informed, which is essential for clear, complete documentation.
C. "Doctor notified of failure to draw ordered blood work."
This documentation lacks the reason for the blood draw failure (patient refusal) and omits the patient’s specific wording.
D. "Refuses to have blood drawn. Doctor notified."
Although this documents the refusal and the doctor’s notification, it omits the patient’s exact words, which can provide additional context for the healthcare team.
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View Related questions
Correct Answer is A
Explanation
A. "What was your daughter's reaction to your desire for hospice?" This is an open-ended question as it invites the patient to share feelings or reactions in a broad, unrestricted way.
B. "Did you sleep all night without waking?" This is a closed-ended question that can be answered with a simple "yes" or "no."
C. "How many bowel movements have you had today?" This is a closed-ended question asking for a specific number.
D. “Is your pain less today than it was yesterday?" This is a closed-ended question that requires a "yes" or "no" answer.
Correct Answer is A
Explanation
A. Follows agency policy for correcting the error.
Following agency policy is the best approach, as it ensures compliance with legal and procedural standards for correcting documentation errors.
B. Whites out the wrong entry and writes the note in the chart of the correct patient. Whiting out errors is not permissible, as it can appear as an attempt to alter records and compromises the integrity of documentation.
C. Removes the page on which the error is located and documents the other correct notes. Removing pages from a medical record is improper and could be considered tampering with documentation.
D. Blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin "wrong patient," his signature, and the date and time.
Blacking out notes is not allowed, as it destroys information that should remain legible, even if it was written in error.