ATI - Chapter 5

Question 1

The chart of medical record is the _____ of care.

Answer 1

legal record

Question 2

The medical record is a confidential, permanent, and _____ document that is admissible in court.

Answer 2

legal

Question 3

Nurses are legally and ethically responsible for ensuring _____.

Answer 3

confidentiality

Question 4

Only health care providers who are involved directly in a client’s care may access that client’s _____.

Answer 4

medical record.

Question 5

Nurses document the care they provide as documentation or charting and it should reflect the nursing ____.

Answer 5

process

Question 6

There is a rapidly growing trend for maintaining medical records _____, which creates challenges in protecting the privacy and safety of health information.

Answer 6

electronically

Question 7

Information to document includes assessments, medication administration, nursing actions, treatments and responses, and ______.

Answer 7

client education

Question 8

______ is a standard for many accrediting agencies, including The Joint Commission mandates the sue of computerized databases to expedite the accreditation process.

Answer 8

documentation

Question 9

Health care facilities use the ________ for budget management, quality improvement programs, research, and many other endeavors.

Answer 9

computerized data

Question 10

Purposes for medical records include communication, legal documentation, financial billing, education, research, and _____.

Answer 10

auditing

Question 11

The purpose of reporting is to provide continuity of care and enhance communication among all team members who provide care to the same clients, thus promoting _____.

Answer 11

client safety

Question 12

Nurses should conduct reporting in a ____ manner.

Answer 12

confidential

Question 13

Elements of documentation

Answer 13

factual - objective and subjective data
accurate and concise
complete and current
organized

Question 14

Nurses should document ____ as direct quotes, within quotation marks, or summarize and identify the information as the client’s statement.

Answer 14

subjective data

Question 15

Subjective data should be supported by objective data so charting is as _____ as possible.

Answer 15

descriptive

Question 16

_____ should be descriptive and should include what the nurse sees, hears, feels, and smells.

Answer 16

objective data

Question 17

Document without derogatory words, judgments, or opinions. Document the client’s behavior ______. Instead of writing “client is agitated”, write “client pacing back and forth in his room, yelling loudly.”

Answer 17

accurately.

Question 18

Document facts and info precisely (what the nurse sees, hears, feels, smells) without any _____ of the situation.

Answer 18

interpretations

Question 19

Unnecessary words and irrelevant details should be _____ in documentation.

Answer 19

avoided

Question 20

Exact measurements establish _____. Only abbreviations and symbols approved by the Joint Commission and the facility are acceptable.

Answer 20

accuracy

Question 21

Document information that is comprehensive and ______. Never pre-chart an assessment, intervention, or evaluation.

Answer 21

timely

Question 22

Communicate information in a logical ______.

Answer 22

sequence

Question 23

Begin each entry with the date and ____.

Answer 23

time

Question 24

Record entries legibly, in non-erasable black ink, and do not leave _____ in the nurses’ notes.

Answer 24

blank spaces

Question 25

Do not use _____, erase, scratch out, or blacken out errors in the medical record. Make corrections promptly, following the facility's procedure for error correction.

Answer 25

correction fluid

Question 26

Sign all documentation as the facility requires, generally with ______.

Answer 26

name and title

Question 27

Documentation should reflect assessments, interventions, and evaluations, not personal opinions or _______ about client or other care care professionals' care.

Answer 27

criticism

Question 28

_____ show trends in vital signs, blood glucose levels, pain level, and other frequent assessments.

Answer 28

flow charts

Question 29

_____ records information as a sequence of events in a story like manner

Answer 29

narrative documentation

Question 30

________ uses standardized forms that identify norms and allows selective documentation of deviations from those norms

Answer 30

charting by exception

Question 31

_______ are organized by problem or diagnosis and consist of a database, problem list, care plan, and progress notes.

Answer 31

problem oriented medical records

Question 32

_______ are replacing manual formats in many settings.

Answer 32

electronic health records

Question 33

Advantages include standardization, accuracy, confidentiality, easy access for multiple users, providing ease in maintaining ongoing health record of client's condition, and rapid acquisition and ______________

Answer 33

transfer of clients information

Question 34

Challenges of ______ include learning the system, knowing how to correct errors, and maintaining security.

Answer 34

electronic medical records

Question 35

Documentation rules and formats are similar in electronic health records to those for ______.

Answer 35

paper charting

Question 36

Nurses give the ______ report at the conclusion of each shift to the nurse assuming responsibility for the clients. Formats include face to face, audiotaping, or _____ during walking rounds in each client's room (unless the client has a roommate or visitor)

Answer 36

change of shift | presentation

Question 37

An effective end of shift report should include significant objective information about the client's ______. Proceed in a logical sequence. Include not gossip or personal opinion. Relate recent changes in medications, treatments, procedures, and the ______.

Answer 37

health problems | discharge plan

Question 38

____ reports are useful when contacting the provider or other members of the interprofessional team.

Answer 38

telephone

Question 39

During the telephone reports it is important to have all the data ready prior to contacting any member of the interprofessional team. Use a professional demeanor. Use _____, relevant, and accurate information. Document the name of the person who made the call and to whom the information was given; the time, _____ and the instructions or information received during the report.

Answer 39

exact | content of the message

Question 40

Telephone or _______ are best to avoid, but they are sometimes necessary during emergencies and at unusual times.

Answer 40

verbal prescriptions

Question 41

During telephone or verbal prescriptions have a _____ nurse listen to a telephone prescription. Repeat it back, making sure to include the medication's name (spell if necessary), dosage, time, and route. _______ any prescription that seems inappropriate for the client.

Answer 41

second | question

Question 42

With telephone or verbal prescriptions make sure the provider signs the prescription in person within the time frame the facility specifies, typically ____.

Answer 42

24 hours

Question 43

______ or hand off reports should include demographic info, medical diagnosis, providers, and overview of health status (physical, psychosocial), plan of care, recent profess, any alterations that might become an urgent or emergent situation, directives for any assessments or client care essential within the next few hours, most recent vital signs, medications and last does, allergies, diet, activity, specific equipment or adaptive devices, advance directives and resucitation status, discharge plan, family involvemtn, and health care proxy.

Answer 43

transfer (hand-off) reports

Question 44

____ or unusual occurrences are an important part of a facility's quality improvement plan.

Answer 44

incident reports

Question 45

An incident is the occurence of an accident or an unusual event. Examples of incidents are medication errors, falls, omission of prescription and _____.

Answer 45

needlesticks

Question 46

In incident reports document facts without judgement or opinion and do not refer to to an incident report in a client's _____.

Answer 46

medical record

Question 47

Incident reports contribute to changes that help improve health care _____.

Answer 47

quality

Question 48

Mandatory adherence with the health Insurance Portability and Accountability Act of 1996 (HIPPA) began in 2003 to help ensure the ________ of health information.

Answer 48

confidentiality

Question 49

A major component of HIPAA, the Privacy Rule, promotes the use of standard methods of maintaining the privacy of protected health information (PHI) among health care _____.

Answer 49

agencies

Question 50

It is essential for nurses to be aware of clients' rights to privacy and confidentiality. Facilities' policies and procedures help ensure adherence with _____.

Answer 50

HIPAA regulations

Question 51

The Privacy rule requires that nurses protect all written and verbal communication about clients. Components of the _____.

Answer 51

privacy rule

Question 52

Only health care team members directly responsible for a client's care may access that client's record. Nurses may not share information with ______ or staff not caring for the client.

Answer 52

other clients

Question 53

Clients have a right to ____ and _____ a copy of their medical record.

Answer 53

read and obtain

Question 54

Nurses may not ______ any part of a medical record except for authorized exchange of documents between facilities and providers.

Answer 54

photocopy

Question 55

Staff must keep medical records in a secure area to prevent inappropriate _____ to information. They may not use public display boards to list client names and diagnoses.

Answer 55

access

Question 56

Electronic records are password protected. The public may not view them. Staff must use only their own ______ to access information.

Answer 56

access

Question 57

Nurses must not disclose clients' information to unauthorized individuals or family members who request it in person or by _____ or email.

Answer 57

telephone

Question 58

Many hospitals use a code system to identify those individuals who may receive information about certain ____.

Answer 58

clients

Question 59

Communication about a client should only take place in a private setting where unauthorized individuals can give the ____.

Answer 59

code

Question 60

Communication about a client should only take place in a private setting where unauthorized individuals cannot _____.

Answer 60

overhear it

Question 61

To adhere to HIPAA regulations, each facility has specific policies and procedures to monitor staff adherence, technical protocols, computer privacy, and ____.

Answer 61

data safety