Chapter 26

Question 1

Documentation

Answer 1

-key communication strategy that produces a written account of pertinent patient data, clinical decisions and inter-ventions, and patient responses in a health record.

Question 2

Health record

Answer 2

-Health care documentation consists of all information entered into a health record, which may be electronic, paper, or a combination of both formats.
-it is also crucial that your documentation accurately reflects the status of the pt. And responses to interventions, especially on admission, transfer, or discharge. You use critical thinking and clinical judgment to ensure that your complete your documentation accurately and completely.
-you document assessment findings and patient information as soon as possible after you provide care (e.g., immediately after providing a nursing intervention or completing a patient assessment).

-Information in a patient’s record provides a detailed account of the level of quality of care delivered.
-The quality of care, the standards of regulatory agencies and nursing practice, the reimbursement structure in the health care system, and legal guidelines make documentation and reporting an extremely important nursing responsibility.

Question 3

Health record information includes:

Answer 3

All health records contain the following information:
• Patient identification and demographic data
• Existence of “living will” or “durable power of attorney for health
care” documents
• Informed consent for treatment and procedures
• Admission data
• Nursing diagnoses or problems and the nursing or interprofessional
care plan
• Record of nursing care treatment and evaluation
• Medical history
• Medical diagnoses

• Therapeutic orders, including code status (i.e., provider order for “do not resuscitate”)
• Medical and interprofessional progress notes (including treatments administered)
• Physical assessment findings
• Diagnostic study results
• Patient education
• Summary of operative procedures • Discharge summary and plan

Question 4

Legal documentation mistakes may include:

Answer 4

(1) failing to record pertinent health or medication informa- tion, (2) failing to record nursing actions, (3) failing to record medica- tion administration, (4) failing to record medication reactions or changes in patients’ conditions, (5) incomplete or illegible records, and (6) failing to document discontinued medications.

Question 5

De-identified data

Answer 5

-De-identification is a process used to prevent a person’s identity from being connected with information. For example, when a data form is used to collect information from a health record, a patient’s name or Social Security number is not entered; instead, a random number is used for labeling and categorizing the form.
- can be used for statistical analysis (e.g., frequency of clinical disorders, complications, use of specific medical and nursing therapies, clinical outcomes achieved during care for specific illnesses, and patient mortality). Analysis of the data contrib- utes to evidence-based nursing practice and high-quality health care

Question 6

Table 26.1 Legal Guidelines for Dicumentation

Question 7

meaningful use of health information technology (HIT)

Answer 7

Meaningful use requires that use of an electronic health record system (EHRS) results in improved quality, safety, and efficiency of health care; increases health care consumers’ active involvement in their care; increases coordination of health care delivery; advances public health; and safeguards the privacy and security of personal health records

Question 8

Difference btwn EHR and EMR

Answer 8

-Although the terms EHR and EMR have been used interchangeably
in practice, there are differences between them. The term electronic health record (EHR) has become the favored term for an individual’s lifetime computerized record; it means both the displayed or printed record. The addition of an “S” at the end of the acronym (EHRS) indi- cates the supporting software system. The term electronic medical record (EMR) refers to a patient’s record within an integrated health care information system for an individual visit to a health care pro- vider’s office or for an individual admission to an acute care setting that allows for seamless documentation of the progression of care. To meet agreed-on standards, EHRs are expected to have the following attributes or components
-• Provide a longitudinal or lifetime patient record by linking all patient data from previous health care encounters.
• Contain a problem list that indicates current clinical problems for each health care encounter, the number of occurrences associated with all past and current problems, and the current status of each problem.
• Use accepted standardized measures to evaluate and record health status and functional levels.
• Provide a method for documenting the clinical reasoning or rationale for diagnoses and conclusions that allows clinical decision making to be tracked by all providers who access the record.
• Support confidentiality, privacy, and audit trails.
• Provide continuous access to authorized users at any time and
allow multiple health care providers access to customized views of
patient data at the same time.
• Support links to local or remote information resources such as
databases using the Internet or intranet resources based within an
agency.
• Support the use of decision analysis tools.
• Support direct entry of patient data by providers.
• Include mechanisms for measuring the cost and quality of care.
• Support existing and evolving clinical needs by being flexible and
expandable.

Question 9

Unique feature of EHR

Answer 9

A unique feature of an EHR is its ability to integrate all patient infor- mation into one record, regardless of the number of times a patient enters a health care system. An EHR also includes results of diagnostic studies that may include diagnostic images (e.g., x-ray or ultrasound images) and decision support software programs. Because an unlimited number of patient records potentially can be stored within an EHR system, health care providers can access clinical data to identify quality issues, link interventions with positive outcomes, and make evidence- based decisions
- The key advantages of an EHR for nursing include a means for nurses to compare current clinical data about a patient with data from previous health care encounters, main- tain ongoing symptom management, and provide an ongoing record of health education provided to a patient and the patient’s response to that information .

Question 10

protected health information (PHI)

Answer 10

• Rule, which specifies administrative, physical, and technical safeguards for 18 specific elements of protected health information (PHI) in electronic form
  -Access to an EHR is traceable through user log-in information. It is unethical to view health records of other patients, and breaches of confidentiality will lead to disciplinary action by employers and potentially dismissal from work or nursing school. To protect patient confidentiality, you must ensure that any electronic or written materials you use in your student clinical prac- tice do not include patient identifiers (e.g., name, room number, date of birth, demographic information). Never print material from an EHR for personal use; any information printed must be for profes- sional use only and should not include identifiable information.

Question 11

Following are steps to enhance fax security

Answer 11

• Always use a cover page.
• For any new recipient, verify the number with a test fax before
sending PHI.
• Follow agency policies for storing, copying, and disposing of faxes
containing PHI.
• Use a fax machine designated exclusively for PHI, and keep it separate
from other fax machines.
• Fax machines must be located in secure, nonpublic areas.
• There must be a robust process in place for password creation and
password changes.
• Providers must be able to prove that their agency has implemented
policies and procedures to protect PHI.
• After faxing something, ensure that the document receipt printed.
• Consider using secure email technologies such as Zsentry.com,
which automatically date and time stamp faxes.

Question 12

Characteristics of quality documentation

Answer 12

Quality nursing documentation enhances efficient, individualized patient care and has five important characteristics: factual, accurate, current, organized, and complete. It is easier to maintain these char- acteristics in your documentation if you continually seek to express ideas clearly and succinctly by doing the following:
• Stick to the facts.
• Write in short sentences.
• Use simple, short words.
• Avoid the use of jargon or abbreviations.

Question 13

[quality documentation]
Factual

Answer 13

A factual record contains clear descriptive, objective informa- tion about what a nurse observes, hears, palpates, and smells. Avoid vague terms such as appears, seems, or apparently. These words suggest you are stating an opinion; they do not accurately communicate facts and do not inform other caregivers about the details regarding the behaviors exhib- ited by a patient. Objective data are obtained through direct observation and measurement and include description of a patient’s behaviors—for example, “BP 90/50, heart rate 115 and regular, patient diaphoretic and holding both hands over abdominal dressing.” The only subjective data included in the record are statements made by a patient. When recording subjective data, document a patient’s exact words within quotation marks whenever possible. Include objective data to support subjective data so that your documentation is as descriptive as possible. For example, instead of documenting “the patient seems anxious,” provide objective signs of anxiety and document the patient’s statement about the feelings experienced: “Patient’s heart rate 110 beats/min, respiratory rate is slightly labored at 22 breaths/min, and patient states, ‘I feel very nervous.’”

Question 14

[quality documentation]
Accurate

Answer 14

Using exact measurements establishes accuracy and helps you determine whether a patient’s condition has changed in a positive or negative way. For example, a description such as “Intake, 360 mL of water” is more accurate than “Patient drank an adequate amount of fluid.” Documenting that an abdominal incision is “Approximated, 5 cm in length without redness, drainage, or edema” is more descriptive than “Large abdominal incision healing well.” Documentation of con- cise data is clear and easy to understand. Avoid using unnecessary words and irrelevant detail. For example, the fact that the patient is watching television is necessary only when this activity is significant to the patient’s status and plan of care.

Question 15

[quality documentation]
Appropriate use of abbreviation in healthcare documentation

Answer 15

Use abbreviations carefully to avoid misinterpretation and promote patient safety.

I-n addition, TJC requires that health care agencies develop a list of standard abbreviations, symbols, and acronyms to be used by all members of the health care team when documenting or communicating patient care and treatment. To mini- mize errors, spell out abbreviations in their entirety when they become confusing.

-Correct spelling demonstrates a level of competency and attention to detail. Many terms are easily misinterpreted (e.g., dysphagia or dysphasia). Some spelling errors can result in serious treatment errors (e.g., the names of medications such as lamotrigine and lamivudine or hydromorphone and hydrocodone are similar). Transcribe medica- tion information carefully to ensure a patient receives the correct medication.

Question 16

[quality documentation]
Dated and timed records

Answer 16

All health care record entries should be dated and timed, and the author of each entry must be clearly identified (TJC, 2021). Each entry in a patient’s record must end with the caregiver’s full name or initials and credentials/title/role, such as “Jane Cook, RN.” If initials are used in a signature, the full name and credentials/title/role of the individual needs to be documented at least once in the health care record to allow others to readily identify that individual. As a nursing student, enter your full name and nursing student abbreviation, such as “David Jones, NS” or “David Jones, SN.” The abbreviation for nurs- ing student varies between NS for nursing student or SN for student nurse. Include information about your educational institution at the end of your signature when required by agency policy.

Question 17

[quality documentation]
Current

Answer 17

Timely entries are essential in a patient’s ongoing care, as delays in documentation can lead to unsafe patient care. Many health care agencies keep records or computers near a patient’s bedside to facilitate immediate documentation of information. Document the following activities or findings at the time of occurrence:
• Vital signs
• Pain assessment
• Administration of medications and treatments
• Preparation for diagnostic tests or surgery, including preoperative
checklist
• Change in patient’s status, treatment provided, and who was notified
(e.g., health care provider, manager, patient’s family) • Admission, transfer, discharge, or death of a patient • Patient’s response to treatment or intervention

Question 18

[quality documentation]
Organized

Answer 18

Application of your critical thinking and clinical judgment skills to the nursing process will help you document clearly and comprehensively in a logical order. For example, an organized entry would describe a patient’s pain, your assessment and interven- tions, and the patient’s response to treatment.

Question 19

[quality documentation]
Complete

Answer 19

Describe any routine data in greater detail when a change in a patient’s functional ability or status occurs. For example, if your patient’s blood pressure, pulse, and respirations are elevated above expected values after a walk down the hall, you would first complete and record a focused assessment in the flow sheet, and then document additional, detailed information about the patient’s status and response to the walk in the appropriate place in the health care record using narrative free text within the flow sheet, or in a narrative progress note.

Question 20

[quality documentation]
Progress notes

Answer 20

-Health care team members monitor and record the progress made toward resolving a patient’s problems in progress notes. Health care providers write narrative progress notes in one of several formats or structured notes within the EHR.
-Notes either take the form of traditional narrative documentation or make use of precise formats such as (1) focus charting, incorporating data, action, and response (DAR); (2) SOAP notes, identifying interprofessional problems; or (3) notes with a specific nursing focus, identifying nursing problems or diagnoses (PIE).

-An example of a comprehensive narrative note written by a nurse looks like this:
1915: Adhering to bed rest as ordered. Left lower extremity is swollen; calf circumference is 76 cm (30 inches). Areas of red- ness that are warm and tender to touch are noted over anterior 3 cm by 4 cm (1.2–1.6 inches) and medial areas 3 cm by 3 cm (1.2 by 1.2 inches) of left leg. Left lower leg elevated on one pillow. Heparin infusing at 1400 units/hr via 20-gauge periph- eral IV in left lower forearm. Site without redness, swelling, or drainage. Verbalizes sharp throbbing leg pain rated at 8 on a 0-to-10 scale. Pedal pulses 3􏰅 bilaterally. Capillary refill in toes of both feet is less than 3 seconds. Oxycodone/acetaminophen 2 tablets (PO) given for pain as ordered. Chris Banks, RN.
2000: States, “The pain medication really helped.” Rates pain in left lower leg at 4 on a 0-to-10 scale. Comfort level goal is 4/10. Chris Banks, RN.

Question 21

BOX 26.1 Examples of Nursing Documentation in Different Formats

Question 22

charting by exception (CBE)

Answer 22

all standards for normal assessment findings or for routine care activities are met unless otherwise documented. Exception-based documentation systems incorporate standards of care and use clearly, predefined statements for the nursing documentation of “normal” body system findings. These normal findings, called “within defined limits” (WDL) or “within normal limits” (WNL), consist of written criteria for a “normal” assessment for each body system. Documentation within a computerized system allows nurses to select a WDL statement or to choose other statements from a drop-down menu that allow description of any unexpected assessment findings or assessment findings that deviate from the WDL definition
-The SBAR or ISBAR format is a commonly used framework for a narrative note when exceptions occur. Both are also popular formats for verbal reporting

Question 23

Patient Care Summary

Answer 23

Many computerized documentation systems generate a patient care sum- mary document that you review (and sometimes print) for each patient at the beginning and/or end of each shift to use as a worksheet for orga- nizing care and in giving the hand-off report.
-The document automatically updates and provides the most current information that was entered into the EHR and usually includes the following information:
• Basic demographic data (e.g., age, religion)
• Health care provider’s name
• Primary medical diagnosis
• Medical and surgical history
• Current orders from the health care provider (e.g., dressing changes,
ambulation, glucose monitoring)
• Nursing care plan
• Nursing orders (e.g., education needed, symptom relief measures,
counseling)
• Scheduled tests and procedures
• Safety precautions used in a patient’s care
• Factors that affect patient independence with activities of daily living
• Nearest relative/guardian or person designated as a patient’s health
care power of attorney to contact in an emergency
• Emergency code status (e.g., indication of do-not-resuscitate order)
• Allergies

Question 24

standardized care plans or clinical practice guidelines (CPGs)

Answer 24

-Each standardized plan facilitates safe and con- sistent care for an identified problem by describing or listing agency standards and evidence-based guidelines that are easily accessed and included within a patient’s EHR
-After completing a nursing assessment, you identify and select the standardized plans that are appropriate for the patient and are to be included in the individualized plan of care. Most computer docu- mentation systems allow these care plans to be modified by creating individualized interventions and outcomes for each patient.

Question 25

Discharge Summary Forms

Answer 25

• Developing a comprehensive plan for a safe discharge relies on interprofessional discharge planning. This process includes identification of key clinical outcomes and appropriate time- lines for reaching them, the appropriate level of care for discharge, and all necessary resources.

•Use clear, concise descriptions in patient’s own language.
• Provide step-by-step description of how to perform a procedure (e.g., home medication administration). Reinforce explanation with printed instructions
for the patient to take home.
• Provide a detailed list of all prescribed medications.
• Identify precautions to follow when performing self-care or procedures
(e.g., dressing change) or taking medications.
• Review any restrictions that may relate to activities of daily living (e.g.,
bathing, ambulating, and driving).
• Review signs and symptoms of complications to report to health care provider.
• List names and phone numbers of health care providers and community
resources for the patient to contact.
• Identify any unresolved problem(s), including plans for follow-up and
continuous treatment.
• List actual time of discharge, mode of transportation, and who accompanied
patient.

Question 26

Guidelines for Telephone and Verbal Orders

Answer 26

• Only authorized staff (who are identified in a written policy by each agency) receive and record telephone and verbal orders.
• Clearly identify the patient’s name, room number, and diagnoses.
• Use clarification questions to avoid misunderstandings. Ask health care
provider to repeat a word or phrase if needed.
• Document “TO” (telephone order) or “VO” (verbal order), including date and
time, name of patient, the complete order; the name and credentials of the health care provider giving the order(s); and your name and credentials as the nurse taking the order.
• Read back all orders prescribed to the health care provider who gave them and document “TORB” (telephone order read back) when signing your name and credentials.
• Follow agency policies; some agencies require TOs and VOs to be reviewed and signed by two nurses.
• The health care provider cosigns each TO and VO within the time frame required by each agency (usually 24 hours).
-Document every phone call you make to a health care provider. Your documentation needs to include when the call was made, the number called, who made the call, who was called, to whom information was given, what information was given, and what information was received. For example: “08/25/2021 (2130): Called Dr. Banks’ office at 123-456-7890. Spoke with L. Matthews, RN, who will inform Dr. Banks that Mr. Andrews’ potassium level drawn at 2000 was 5.9 mEq/dL. Informed that Dr. Banks will call back after he is finished seeing his current patient. R. Jenner, RN.”
-A nurse receiving a TO or VO enters the complete order into the computer by using the computerized provider order entry (CPOE) software or writes it out on a physician’s order sheet for entry into the computer as soon as possible. TJC requires that the receiver of a VO or TO record it and read (not repeat) it back to the prescriber.

-this ensures that one has not only heard an order correctly but also tran-scribed it accurately (ISMP, 2017). For example, document a TO as follows: “09/30/2021 (1015), Change IV fluid to Lactated Ringers with potassium 20 mEq/L to run at 125 mL/h. TO: Dr. Knight/K. Day, RN, telephone order read back (TORB).” The health care provider later verifies the TO or VO legally by cosigning it within a time frame (e.g., 24 hours) set by agency policy.

Question 27

incident report or occurrence report

Answer 27

-any event that is not consistent with the routine, expected care of a patient or the standard procedures in place on a health care unit or within an agency
- completed whenever an incident occurs.

-Follow agency policy when completing an incident report and file the report with your agency’s risk-management department. When an incident occurs, document an objective description of what happened, what you observed, and the follow-up actions taken, including notifica- tion of the patient’s health care provider in the patient’s health care record. Remember to evaluate and document the patient’s response to the incident in the health care record as well. Do not label this as an “incident,” “near miss,” or “sentinel event” in the health care record, and do not make any reference to these types of documents.

Question 28

acuity rating systems

Answer 28

• determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours.
• determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours. A patient’s acuity level, usually determined by the assessment data an RN enters into a computer program, is based on the type and number of nursing interventions (e.g., intravenous [IV] therapy, wound care, or ambulation assistance) required by that patient over a 24-hour period.
  -The acuity level is a classification that compares one or more patients with another group of patients. An acuity system classifies patients from 1 (independent in all but one or two aspects of care; almost ready for discharge) to 5 (totally dependent in all aspects of care; requiring intensive care).

Question 29

case management model and use of critical pathways

Answer 29

-incorporates an interprofessional approach to delivery and documentation of patient care
-Critical pathways (also known as clinical pathways, practice guidelines, or CareMap tools) are interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an estab- lished time frame

Question 30

Variances

Answer 30

-Unexpected outcomes and interventions not specified within a critical pathway are called variances.
-A variance occurs when the activities on the critical pathway are not completed as predicted or a patient does not meet the expected outcomes.
- A positive variance occurs when a patient makes progress faster than expected (e.g., an indwelling urethral catheter is discontinued a day earlier than anticipated according to the critical pathway).
-An example of a negative variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. Variances to expected outcomes are documented with a progress note
-Over time, health care teams some- times revise critical pathways if similar variances recur.

Question 31

BOX 26.4 Example of Variance Documentation

Answer 31

An RN working in the case management role is using a critical pathway for “Routine Postoperative Care” for a 56-year-old man who had abdominal surgery yesterday. One of the expected outcomes for postoperative day 1 on the critical pathway document is “Afebrile with lungs clear bilaterally.” This patient has an elevated temperature, his breath sounds are decreased bilaterally in the bases of both lobes of the lungs, and he is slightly confused.
The following is an example of how the RN case manager documents this variance on the pathway:
“Breath sounds diminished bilaterally at the bases. T-100.4; P-92; R-28/min; pulse oximetry 84% on room air. Daughter states he is “confused” and did not recognize her when she arrived a few minutes ago. Oxygen 2 L via nasal cannula started per standing orders. Oxygen saturation improved to 92% after 5 minutes. Dr. Lopez notified of change in status. Daughter remains at bedside.”

Question 32

Health information technology (HIT)

Answer 32

-the use of information systems and other information technology to record, monitor, and deliver patient care, and to perform managerial and organizational functions in health care
-The focus of HIT is the patient and the process of care, and the goal of using HIT is to enhance the quality and efficiency of care provided.

Question 33

health care information system (HIS)

Answer 33

-consists of “computer hard- ware and software dedicated to the collection, storage, processing, retrieval, and communication of patient care information in a health- care agency”
-An HIS consists of two major types of information systems: a clinical information system and an adminis- trative information system. Together the two systems operate to make the entry and communication of data and information more efficient.

Question 34

clinical information system (CIS) (also known as a patient care information system)

Answer 34

-a large, computerized database management system that is used to access patient data needed to plan, implement, and evaluate care
-A CIS can include monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems. A monitoring system often includes devices that automati- cally monitor and record biometric measurements (e.g., vital signs and oxygen saturation) in acute care, critical care, and specialty care areas. Some of these devices can be programmed to electronically send mea- surements directly to a nursing documentation system, decreasing nursing workload.

Question 35

computerized provider order entry (CPOE)

Answer 35

-allows health care providers to directly enter standardized, legible, and complete orders for patient care into a medical record from any computer in the HIS.
-In addition, a CPOE system potentially speeds the implementation of ordered diagnostic tests and treatments, which contributes to high- quality care and better patient outcomes. A CPOE system improves reimbursements because some orders require preapprovals from insur- ance plans. CPOE, when integrated with an electronic practice management system, can flag orders that require preapproval, helping a health care agency reduce denied insurance claims
-Use of a CPOE system has been shown to improve productivity and cost-effectiveness in the communication and implementation of health care provider orders. More important, most CPOE systems have significant potential to reduce medication errors associated with inappropriate drug use and dosing

Question 36

nursing clinical information system (NCIS)

Answer 36

-incorporates the principles of nursing informatics to support the work that nurses do by facilitating documentation of nursing process activities and offering resources for managing nursing care delivery.
-NCISs have two designs. The nursing process design is the most traditional. It organizes documentation within well-established formats such as admission and postoperative assessment problem lists, care plans, intervention lists or notes, and discharge planning instructions. The nursing process design facilitates the following:
• Generation of a nursing work list that outlines routine scheduled care activities for a patient
• Documentation of routine aspects of patient care such as hygiene, positioning, fluid intake and output, wound care measures, and blood glucose measurements
• Progress note entries: narrative notes, charting by exception, and/or flow sheets
• Documentation of medication administration

The other model for an NCIS is the protocol or critical pathway
design. CIS is the protocol or critical pathway
design (Hebda et al., 2019). This design facilitates interprofessional management of information because all health care providers use evidenced-based protocols or critical pathways to document the care they provide. The information system allows a user to select one or more appropriate protocols for a patient. An advanced system merges multiple protocols, using a master protocol or path to direct patient care activities. Standard health care provider order sets are included in the protocols and automatically processed. The system also integrates appropriate information into the medication delivery process to enhance patient safety.

Question 37

clinical decision support system (CDSS)

Answer 37

computer program that aids and supports clinical decision making. The knowledge base within a CDSS contains rules and logic statements that link information required for clinical decisions to generate tailored recommendations for individual patients; the recommendations are presented to health care providers as alerts, warnings, or other information for consideration

Question 38

Nursing informatics

Answer 38

-specialty that integrates nursing science, computer science, and information science to manage and com- municate data, information, knowledge, and wisdom in nursing and informatics practice
-Nursing informatics is recognized as a specialty area of nursing practice at the graduate level. Nurses who specialize in informatics have advanced knowledge in information management and demonstrate proficiency with informatics to support all areas of nursing practice, including QI, research, project management, and system design

Question 39

Summary

Answer 39

• The health care record facilitates interprofessional communication, provides a legal and financial record of care, aids in clinical educa- tion and research, and guides professional and agency performance improvement.
• Nursing documentation supports reimbursement to health care agencies through accurate accounting of the use of services and equipment and medications administered.
• Effective nursing documentation limits liability through objective description of what happened to a patient and clearly indicates that individualized, outcome-directed nursing care was provided based on nursing assessment.
• A variety of methods, such as limiting who can access electronic health records, firewalls, spyware detection software, automatic sign-offs, and the use of strong passwords are used to secure the confidentiality of PHI in the EHR.
• Only members of the health care team who are directly involved in a patient’s care have legitimate access to a patient’s health record; follow agency policies that describe the sharing of medical records.
• Quality documentation is factual, accurate, detailed, and timely, and incorporates precise measurements, correct spelling, and proper use of abbreviations.
• Patient safety is enhanced when health care professionals eliminate the use of dangerous abbreviations, acronyms, symbols, and dose designations from their documentation.
• Nurses use a variety of forms when admitting patients, providing nursing care, and discharging patients to document patient care. Documentation requires nurses to be skilled in the use of checklists, flow sheets, and narrative notes regardless of whether they document electronically or on paper.
• Documentation of a safe plan for discharge includes information given on medications, diet, community resources, follow-up care, and contact information for whom to call with questions or in case of an emergency.
• When information relevant to care is communicated by telephone, documentation includes when the call was made, the number called, who made the call, who was called, to whom information was given, what information was given, what information was received, and verification of information through use of a read-back process.
• Health care informatics facilitates the integration of data, informa- tion, knowledge, and wisdom to support patients, nurses, and other providers in decision making in all roles and settings.
• Nursing students must develop the knowledge, skills, and atti- tudes that will enable them to use information and technology to communicate, manage knowledge, mitigate error, and support decision making. For example, nursing students need to know how to document in an EHR, value technologies that support clinical decision making, and respond appropriately to clinical decision-making alerts.
• Using a recent clinical experience, describe how a CDSS could support evidence-based practice, allowing you to make decisions that would result in safe and effective nursing actions.
• Imagine there is an increased incidence of pressure injuries among the patients on the unit where you have clinical. Describe what data you could collect from the agency’s nursing information system to determine why these patients are at greater risk for skin breakdown and what factors related to the nursing care provided on the unit are influencing the prevalence of hospital-acquired pressure injuries. Discuss why this information is important to collect.

Question 40

Reflective learning

Answer 40

• Describe the actions you will take to protect the privacy of patient in- formation if you need to print information from an EHR during clinical to complete your clinical paperwork after returning to campus.

• Using a recent clinical experience, describe how a CDSS could support evidence-based practice, allowing you to make decisions that would result in safe and effective nursing actions.
• Imagine there is an increased incidence of pressure injuries among the patients on the unit where you have clinical. Describe what data you could collect from the agency’s nursing information system to determine why these patients are at greater risk for skin breakdown and what factors related to the nursing care provided on the unit are influencing the prevalence of hospital-acquired pressure injuries. Discuss why this information is important to collect.

Question 41

QSEN Building compentency in Informatics

Answer 41

A patient diagnosed with a deep vein thrombosis (DVT) in the left lower leg was admitted 3 days ago and has been receiving a continuous heparin infusion of 1300 units/hr via a peripheral IV catheter located in the left lower forearm. You are the RN caring for this patient from 1500 to 2300 today, and you learn during the hand-off report that the patient’s most recent partial thromboplastin time (PTT) is 70 seconds, indicating that the current dose of heparin infusing at 1300 units/h is therapeutic (Pagana et al., 2019). The outcome for this patient is to establish therapeutic anti- coagulation levels by using warfarin (an oral anticoagulant) so that the heparin in- fusion can be discontinued. The patient will be discharged with a prescription for warfarin, which will be taken daily for 6 months until the DVT has resolved. The patient received the first dose of warfarin 10 mg orally (PO) yesterday evening.
The patient’s next dose of warfarin 10 mg PO is due at 1800. You log on to the computer located in the patient’s room at that time and open the medication administration record in the patient’s EHR. As you scan the package of warfarin using the bar-code medication administration function, a warning statement pops up on the computer screen: “Review most recent PT/INR results before administration.” You switch screens in the EHR to review the patient’s labora- tory results and note that the patient’s most recent prothrombin time (PT) was 21 seconds, and the international normalized ratio (INR) was 2.3, indicating that the dose of warfarin that the patient received yesterday was too high and that the patient has a critically increased risk for bleeding (Pagana et al., 2019). The abnormal results are displayed in a red font in the EHR, and a notation reading “Critical Value” is displayed next to each of the results displayed in red. What does the warning statement that popped up on the computer screen represent? What is the most appropriate action for you to take in this situation?

Question 42

A nurse contacts the health care provider about a change in a patient’s condition and receives several new orders for the patient over the phone. When documenting telephone orders in the EHR, what should the nurse do?
1. Print out a copy of all telephone orders entered into the EHR in order to keep them in personal records for legal purposes.
2. “Read back” all telephone orders to the health care provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the EHR.
3. Record telephone orders in the EHR but wait to implement the order(s) until they are electronically signed by the health care provider who gave them.
4. Implement telephone order(s) immediately but insist that the health care provider come to the patient care unit to personally enter the order(s) into the EHR within the next 24 hours.

Answer 42

2

Question 43

You are a nurse who is working in an agency that has recently implemented an EHR. Which of the following are acceptable practices for maintaining the security and confidentiality of EHR information? (Select all that apply.)
1. Using a strong password and changing your password frequently according to agency policy
2. Allowing a temporary staff member to use your computer user- name and password to access the electronic record
3. Ensuring that work lists (and any other data that must be printed from the EHR) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed
4. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient’s care
5. Remaining logged into a computer to save time if you only need to step away to administer a medication

Answer 43

1.3.4.

Question 44

When documenting an assessment of a patient’s cardiac system in an EHR, the nurse uses the computer mouse to select the “WNL” state- ment to document the following findings: “Heart sounds S1 & S2 auscultated. Heart rate between 80 and 100 beats/min, and regular. Denies chest pain.” This is an example of using which of the following documentation formats?
1. Focuschartingincorporatingdata,action,andresponse(DAR)
2. Problem-intervention-evaluation (PIE)
3. Charting by exception (CBE)
4. Narrative documentation

Answer 44

3

Question 45

The nurse works at an agency where military time is used for docu- mentation and needs to document that a patient was medicated for pain after midnight. Identify the correct military time to document medication administered at 12:05 a.m.

1. 2405
2. 0005
3. 2205
4. 1205

Answer 45

2

Question 46

The nurse who works at the local health care agency is transferring a patient to an acute rehabilitation center in another town. To com- plete the transfer, information from the patient’s EHR must be printed and faxed to the acute rehabilitation center. Which of the following actions are appropriate for the nurse to take to maintain privacy and confidentiality of the patient’s information when faxing this information? (Select all that apply.)
1. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax.
2. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute reha- bilitation center to read the information unless they have the encryption key.
3. Fax the patient’s information without a cover sheet so that the person receiving the information at the acute rehabilitation center can identify it more quickly.
4. After sending the fax, place the information that was printed out in a standard trash can after ripping it into several pieces.
5. After sending the fax, place the information that was printed out in a secure canister marked for shredding.

Answer 46

1.2.5

Question 47

The nurse is administering a dose of metoprolol to a patient and is completing the steps of bar-code medication administration within the EHR. As the bar-code information on the medication is scanned, an alert that states, “Do not administer dose if apical heart rate (HR) is <60 beats/min or systolic blood pressure (SBP) is <90 mm Hg” appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system?
1. Electronic health record (EHR)
2. Charting by exception
3. Clinical decision support system (CDSS)
4. Computerized provider order entry (CPOE)

Answer 47

3

Question 48

The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O):
1. April 24, 2021 (0900)
2. Repositioned patient on left side.
3. Medicated with hydrocodone-acetaminophen 5/325 mg,
2 tablets PO.
4. “The pain in my incision increases every time I try to turn on
my right side.”
5. S.Eastman,RN
6. Surgical incision right lower quadrant, 3 inches in length, well
approximated, sutures intact, no drainage.
7. Rates pain 7/10 at location of surgical incision.

Answer 48

1. O
2. O
3. O
4. S
5. O
6. O
7. O

Question 49

The nurse is discussing the advantages of using CPOE with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an EHR?
1. CPOE reduces the time necessary for health care providers to write orders.
2. CPOE reduces the time needed for nurses to communicate with health care providers.
3. Nurses do not need to acknowledge orders entered by CPOE in an EHR.
4. CPOE improves patient safety by reducing transcription errors.

Answer 49

4

Question 50

The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contains an inappropriate abbreviation included on TJC’s “do not use” list and
should be clarified with the health care provider?
1. Change open midline abdominal incision daily using wet-to-
moist normal saline and gauze.
2. Lorazepam 0.5 mg PO every 4 hours prn anxiety
3. Morphine sulfate 1 mg IVP every 2 hours prn severe pain
4. Insulin aspart 8u SQ every morning before breakfast

Answer 50

4

Question 51

The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most ap- propriate way for the nurse to document this conversation?
1. Health care provider notified about change in assessment of abdominal incision. T. Wright, RN
2. 09-3-21: Notified the surgeon by phone that there is a new area of redness around the patient’s incision. T. Wright, RN
3. 1015: Contacted the surgeon and notified about changes in
abdominal incision. T. Wright, RN
4. 09-3-21 (1015): Surgeon contacted by phone. Notified about
new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN

Answer 51

4