Big Daddy (7) Flashcards
How does a healthcare policy assure access to health information by authorized users?
It creates a reliable method to verify the identities of users accessing health information.
A patients glucose blood sugar is 400. What is a one-time kind of report?
Ad Hoc
Which clinical information technology enables providers to document patient assessments?
Vitals signs capture
Which is a physician’s clinical informatics assessment?
Vital signs
The nurse receives report that there are new orders to review. Where does the nurse look to verify this information?
The Kardex
Which area of the EHR is used to guide a nurse on the tasks that need to be completed during the shift?
The worklist
Which type of chart uses rectangle, oval & diamonds in both?
Flowchart
On admission, a patient reports several allergies. Where does the nurse confirm the documentation of this information?
In the patient summary tab
Where are POLST (advanced care directives) found on the computer?
Media tab
- Provider wants you to change an order what tab would you look under?
Order summary tab
- When a physician arrives on the unit, a nurse is asked about the fluid status of a patient. Where should the nurse find this information?
The intake & output chart
High pt volume
Nursing flowsheet
MRSA
contact precautions
A Nursing Innovator & medsurg nurse want to capture how many patients were seen in a day of 24 hours, how would they best see this?
Flowsheet
Pts come in complaining of the same S/S
pt demographics
Pt discharge, information planning
History & physical notes about the reason the pt is admitted anyways
Where do you document a patient’s allergy?
History & physical
Suspected dehydration & pt reports dizziness with H/A & decreased u/o
Lab Report
Pt comes to the ED with a bump on the arm that is painful, edematous, & oozing sanguineous fluid. Which data in the pt’s medical record would tell a nurse to implement infection control precautions?
The nursing flow sheet states the wound has increased in edema, redness, & drainage over the last 12 hours
COPD pt planning care
complete health history
A restraint committee has been assembled to oversee the need & proper usage of restraints. It has asked a report to be constructed to allow better tracking of restraint usage & documentation compliance throughout the organization. Which data element would this committee find least useful in this report?
Patient allergy history
Reported falls on the med surg unit as compared to the previous quarter. Which data set informs the decision to review the protocol for falls on the med-surg unit?
The radiology reports of pts with a reported fall on the med-surg unit
Which data in a medical record informs the management of the pt’s condition following a surgical procedure?
Nursing assessment from the prior shift & the doctor’s orders
is a standard person-identifier code that uniquely identifies an individual and permits the correlation process to match the person’s data from a variety of different sources of health providers (e.g., clinics, hospitals, pharmacies, and nursing homes).
A master patient index (MPI)
