Chapter 26 Informatics And Documentation

Question 1

Porposes of the health care records

Answer 1

1-Facilitates interprofessional communication among health care
providers
2-Legal record of care provided
3-Justification for financial billing and
reimbursement of care
4-Auditing, monitoring, and evaluation of care provided
5-Education and research

Question 2

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 patients
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.

Answer 2

Factual (FOR QUALITY

NURSING DOCUMENTATION)

Question 3

Guidelines for Quality Documentation

Answer 3

Factual
Accurate
Current
Organized
Complete

Question 4

Documentation of patient assessment

data

Answer 4

Flow sheets
Progress notes(narrative documentation)
Charting by exception

Question 5

3. A nurse records that the patient stated his abdominal pain is
   worse now than last night. This is an example of:
   A. PIE documentation.
   B. SOAP documentation.
   C. narrative charting.
   D. charting by exception.

Answer 5

C

Question 6

5-What does the acronym SOAP stand for?

Answer 6

S: Subjective
• O: Objective
• A: Assessment
P. Plan:

Question 7

Common Record-
Keeping Forms within the
Electronic Health Record

Answer 7

Admission nursing history form
Patient care summary
Care plans
Discharge summary forms

Question 8

Nurses use two different data sets to
document clinical assessments and
care provided in the home care setting

Answer 8

OASIS

Omaha system

Question 9

4. A patient you are assisting has fallen in the shower. You must
   complete an incident report. The purpose of an incident report is
   to:
   A. exchange information among health care members.
   B. provide information about patients from one unit to another unit.
   C. ensure proper care for the patient.
   D. aid in the hospital’s quality improvement program.

Answer 9

D

Question 10

When documenting an assessment of a patient’s cardiac system in
an electronic health record, the nurse uses the computer mouse to
“WNT»
select the “WNI’ statement to document the following findings:
“Heart sounds S1 e S2 auscultated. Heart rate between 80-100 beats
per minute, and regular. Denies chest pain.” This is an example of
using which of the following documentation formats?
1. Focus charting incorporating “Data, Action & Response” (DAR)
2.
Problem-intervention-evaluation(PIE)
3. Charting-by-exception(CBE)
4. Narrative documentation

Answer 10

3

Question 11

6. The nurse is administering a dose of metoprolol to a patient, and
   is completing the steps of bar code medication administration
   within the EH. 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/minute 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?
7. Electronic health record (EHR)
8. Charting by exception
9. Clinical decision support system (CDSS)
10. Computerized physician order entry (CPOE)

Answer 11

3