Chapter 10

Question 1

(Info) The purpose of documentation is,

Answer 1

1. To reflect the type and frequency of care 2. to provide accountability for each health care team member 3. also provides evidence for credentialing, 4. research, 5. reimbursement, 6. and a database for planning care

Question 2

(Info) Medicare does not reimburse for,

Answer 2

Preventable conditions like hospital acquired illnesses and injuries

Question 3

(Info) HIPPA does what?

Answer 3

1. Provides legislation to protect patient privacy, 2. governs all aspects of health information management (reimbursement, medical record coding, security, patient record management)

Question 4

(Info) TJC requires all admitted patients be assessed for,

Answer 4

1. Physical, 2. psychosocial, 3. environmental, 4. self-care, 5. knowledge level 6. and discharge planning needs

Question 5

(Info) A patients record is,

Answer 5

A confidential chart that is a permanent legal document of information relevant to the patients health care

Question 6

(Info) A report is,

Answer 6

An oral, written, or audio tapes exchange of information between members of the emhealth care team

Question 7

(Info) The five characteristics of quality documentation and reporting are,

Answer 7

1. Factual, 2. accurate, 3. complete, 4. current, 5. and organized

Question 8

(Info) EHR

Answer 8

Electronic health record contains information from one or more visits

Question 9

(Info) EMR

Answer 9

Is apart of the EHR, data from a specific place and time

Question 10

(Info) Meaningful use means,

Answer 10

Refers to the level with with IT is available and used to support clinical decision making to improve quality, safety, and efficiency.

Question 11

(Info) POMR

Answer 11

Problem-orientated medical record. Structured method of documentation that emphasizes the patients problems (SOAP, PIE)

Question 12

(Info) Focus charting

Answer 12

Unique narrative format that places less emphasis on patients problems and instead focuses on patient concerns (DAR)

Question 13

(Info) Charting by exception (CBE)

Answer 13

Using a check mark on a flow sheet to indicate normal findings or routine interventions. Only write narrative information only if findings are abnormal. Cuts down on charting time

Question 14

(Info) Case management plan

Answer 14

Using an interdisciplinary approach to document patient care and focuses on providing quality care in a cost-effective manner. Incorporated critical pathways (care maps)

Question 15

(Info) Admission nursing history form

Answer 15

Provides baseline data for later comparisons

Question 16

(Info) Flow sheets/graphic records

Answer 16

Apart of the permanent health record, allow repeated documentation of a certain routine (vitals, pain assessment). Used to observe trends and often in critical care

Question 17

(Info) Kardex

Answer 17

Patient care summary

Question 18

(Info) Standardized care plan

Answer 18

Make documentation more efficient. Guidelines of care for patients with similar health problems.

Question 19

(Info) Acuity recording

Answer 19

Determines the number of hours of care for a nursing unit and the number of staff required to care for a given group of patients.

Question 20

(Info) CMS

Answer 20

Centers for Medicare and Medicaid

Question 21

(Info) Hand off report

Answer 21

Anytime one health care provider transfers care to another health care provider

Question 22

(Info) Change of shift report

Answer 22

Hand off report that occurs at the end of each shift

Question 23

(Info) Transfer report

Answer 23

Hand off report that involves communication of information about patients from the nurse on the sending unit to the nurse on the receiving unit

Question 24

(Info) A nurse will make a telephone report when,

Answer 24

Significant events of changes in a patients condition occur. Use SBAR to minimize errors. Always document phone calls

Question 25

(Info) SBAR

Answer 25

Situation, background. Assessment, recommendation. Standardizes communication.

Question 26

(Info) An incident report is also called an…

Answer 26

Occurrence or event report.

Question 27

(Info) When reporting an incident…

Answer 27

Do not mention that an error occurred in the medical record, objectively explain what happened, what you observed, and how you followed up.

Question 28

(Info) Health informatics

Answer 28

Facilitates the 1. acquisition, 2. processing, 3. interpretation, 4. optimal use, 5. and communication of health related data

Question 29

(Info) Informatics

Answer 29

The science and art of turning data into information

Question 30

(Info) Three major purposes for the medical record

Answer 30

1. Communication, 2. education, 3. research

Question 31

(Info) HITs

Answer 31

Health information technology

Question 32

(Info) CPOE

Answer 32

Computerized provider order entey

Question 33

(Info) Advantages of CPOE are,

Answer 33

1. Reduced use resources, 2. quicker turnaround of orders, 3. reduced length of stay, 4. an overall reduction in cost, 5. and a reduction in medication errors

Question 34

(Info) BCMA

Answer 34

Barcode medication administration

Question 35

(info) FTEs

Answer 35

Full time equivalents

Question 36

(info) HIS

Answer 36

Health care information system. Group of systems used within a health care enterprise that support and enhance health care

Question 37

(Info) 1. TO 2. VO 3. Both

Answer 37

1. Telephone order 2. Verbal order 3. Frequently cause medical errors

Question 38

(Info) The HIS include what two parts?

Answer 38

The administrative information system and the clinical information system (CIS)

Question 39

(Info) CISs are used for

Answer 39

Supporting the planning implementation, and evaluation of patient care

Question 40

(info) NIS

Answer 40

Nursing information systems

Question 41

(Info) NISs support what?

Answer 41

The documentation of the nursing process, and management of nursing care delivery

Question 42

(Info) CDSS

Answer 42

Clinical decision support system. Programs used within a health care setting to provide you with clinical knowledge and relevant patient information to help you improve patient care.

Question 43

(Info) The most common risk for using an electronic system?

Answer 43

Hacking leading to breaches in patient privacy, patient confidentiality, and security.

Question 44

(Info) Privacy

Answer 44

Individuals right to limit access to their health care information

Question 45

(Info) Confidentiality

Answer 45

The expectation that information shared with health care providers will only be used for its intended purpose.

Question 46

(Info) HIPPA addresses standardizing electronic transmission of health information by…

Answer 46

Focusing on the need to protect security, integrity, and authenticity of the information

Question 47

(Info)PHI

Answer 47

Personal Health Information (SSN, DOB, name, address)

Question 48

(Info) When taking a telephone order from a health care provider, it is common for most organizations to require the nurse to: 1 photocopy the order for your records 2 write the order in its entirety and read it back to the health care provider for verification 3 write the order but do not implement until it has been signed by the health care provider 4 take the order from the health care provider but insist that the health care provider come to the patient care division to write the order themselves

Answer 48

2 Guidelines from TJC require a read-back on all verbal and telephone orders. The nurse reads it back, called read-back, and receives confirmation from the person who gave the order.

Question 49

(Info) Which action is acceptable practice when documenting in an electronic health record? 1 allowing a temporary staff member to use your computer user name and password 2 remain logged in to a computer when you leave to administer a medication 3 allowing the health care prover covering your patient to quickly input an order using you computer password 4 preventing other from seeing a display monitor that contains patient information

Answer 49

4 According to guidelines for use of EHR, the health care provider/nurse should not share passwords, should avoid leaving computer unattended, and should avoid leaving information about a patient displayed on a monitor where others can see it.

Question 50

(Info) You have been teaching a patient about a new medication for a recently diagnosed heart condition. To document this in the progress notes, you record the data, action, and evaluation of response to the teaching. This type of charting format is called 1 POMR 2 CBE 3 PIE 4 focus charting

Answer 50

4 Focus charting is a unique narrative format that focuses on patient concerns such as a sign or symptom, condition, behavior, or significant event; each entry includes data, actions, and patient response (DAR) for the particular patient situation.

Question 51

(Info) Your facility has started to use military time. Your patient received a one time does of the diuretic furosemide 40 mg IV at 3 PM. How should you document the administration time? Pt received furosemide 40 mg IV at, 1 1500 hours 2 2100 hours 3 1300 hours 4 0300 hours

Answer 51

1 The military clock begins at 1 minute after midnight as 0001 and ends with midnight at 2400. Noon is 1200. 1 pm is 1300; 2 pm is 1400, and 3 pm is 1500.

Question 52

(Info) You are giving a hand off report to another nurse who will be caring for your patient at the end of you shift. Which f the following pieces of information do you include in the report? Select all that apply 1 PTs name, age, and admitting diagnosis 2 allergies to food and medications 3 your evaluation that the patient is “grouchy” 4 how much the patient has urinated 5 that the patients pain rating went from 6 > 3 on a scale of 0 > 10 after receiving 325 mg of Tylenol 6 did not receive dressing change because of inadequate staffing during the previous shift

Answer 52

1, 2, 4, 5 Legal guidelines for recording include that you do not write retaliatory or critical comments about patient or care by other health care professionals.

Question 53

(Info) What is an appropriate way for a nurse to dispose of the printed patient information? 1 rip several time and place in a standard trash can 2 place in the PTs paper based chart 3 place in a secure canister marked for shredding 4 burn the documents

Answer 53

3 The nurse has the obligation to safeguard any patient information that is printed from the electronic record or extracted for report purposes. The information is considered personal health identifiers. Best practice is to shred anything that is printed.

Question 54

(Info) A nurse caring for a PT who has hypertension documents a systolic blood pressure of 1200 mm Hg. Suddenly an alert warning appears on the screen warning the nurse that the number entered exceeds the range for human systolic blood pressure and that the value entered needs to be reviewed. This warning is known as what type of system? 1 electronic health record 2 clinical documentation 3 clinical decision support system 4 computerized physician order entry

Answer 54

3 CDSSs are computerized programs used within the health care setting to provide you with clinical knowledge and relevant patient information to help you improve patient care. They use a complex system of rules for analyzing data and present information to support the decision-making process of the nurse. The CDSS provides an alert if the data entry falls outside of the safe range, and the provider is given the information. A BP of 1200 was probably a typing error. The nurse probably intended to type a systolic BP of 120. With the CDSS the inaccurate information was not allowed to be recorded.

Question 55

(Info) A group of nurses is discussing the advantages of using computerized provider order entry. Which of the following statements best indicated that the nurses understand the major advantages of using it? 1 CPOE reduces transcription errors 2 CPOE reduces the time necessary for health care provider to write orders 3 health care providers can write orders from any computer that has internet access 4 CPOE reduces the time nurses use to communicate with the health care providers

Answer 55

1 Although the other answers are correct, the best answer indicating the major advantage has to do with reduction of transcription errors, which creates a safer patient care environment and reduces medical errors.

Question 56

(Info) A PT had back surgery yesterday. During the dressing change you notice an increase in serosanguinous doing from the incision. Because this is a deviation from the written assessment guidelines, you document this observation on the assessment flow sheet. This type of charting system is called 1 POMR 2 charting by exception 3 narrative 4 focus

Answer 56

2 CBE is a method of documentation that relies on preestablished agency criteria for nursing assessments and standards of practice for nursing interventions. As a result you use a check mark on the flow sheet to indicate normal findings or routine interventions. You write narrative information only if findings are abnormal.

Question 57

(Info) Match the correct definition with the appropriate terminology related to electronic medical records 1 privacy 2 security 3 confidentiality A expectation that info will be used only for its intended purpose B individuals right to limit access to their health care info C protection from unauthorized access, malicious damage, and incidental and accidental damage

Answer 57

1=b, 2=c, 3=a Privacy is the individual’s right to limit access to his or her health care information. Confidentiality is the expectation that information shared with the health care provider will be used only for its intended purposes. Security protects the EHR from hackers who try to attain confidential information