Documentation

Question 1

Documentation systems allow members of the healthcare care team to

Answer 1

Efficiently document and retrieve clinical data, track patient outcomes, and facilitate continuity of care

Question 2

Regulators of documentation

Answer 2

The joint commission, legal and legislative bodies, Centers for Medicare Services (CMS), insurance companies, quality assurance departments

Question 3

Centers for Medicare Services (CMS) is responsible for

Answer 3

Reimbursement

Question 4

Purposes of the health care record

Answer 4

Interprofessional communication, legal record, financial billing and reimbursement, auditing/monitoring/evaluation of care, education and research

Question 5

What is the difference between an EHR and EMR?

Answer 5

EMR is the actual application (Ex: CERNER, EPIC), while EHR is WITHIN the EMR (patient health records)

Question 6

Nurses are legally and ethically obligated to keep all patient information __________

Answer 6

Confidential

Question 7

Patient status can only be discussed with

Answer 7

Members of the health care team

Question 8

T or F: Patient data can be used for research or continuing education

Answer 8

True, but permission is needed

Question 9

Information regarding a patient’s health status may not be releases to non-health care tram members because

Answer 9

Legal and ethical obligations require health care providers to keep information strictly confidential unless express written consent is given by the patient

Question 10

Public health information (PHI) that can be given

Answer 10

Billing information

Question 11

Examples of physical security measures for privacy and confidentiality

Answer 11

Placing computers or file servers in restricted areas, using privacy filters for computer screens visible to visitors or others without access

Question 12

Guidelines for quality documentation

Answer 12

Factual, accurate and authenticated, current, organized, complete and timely, clear and concise

Question 13

Documentation subjective data

Answer 13

Record patient’s statement word for word in quotation marks

Question 14

A nurse has just admitted a patient with a medical Dx of CHF. When completing admission paperwork, the nurse needs to record

Answer 14

Objective data observed

Question 15

Methods of documentation

Answer 15

Flow sheets, progress notes, charting by exception, SBAR, DAR

Question 16

DAR method of documentation

Answer 16

Data (objective/subjective), Action (interventions), Response (evaluation)

Question 17

SBAR method of documentation

Answer 17

Situation, background, assessment, recommendation

Question 18

Method of documentation characterized by only charting abnormal data

Answer 18

Charting by exception

Question 19

A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of what method of documentation?

Answer 19

Narrative charting

Question 20

PIE method of documentation

Answer 20

Problem, intervention, evaluation

Question 21

SOAP method of documentation

Answer 21

Subjective, objective, assessment, plan

Question 22

Common record keeping forms within the EHR

Answer 22

Admission nursing history form, patient care summary, care plans, discharge summary forms

Question 23

T or F: the nurse should document every phone call made to a health care provider

Answer 23

True

Question 24

The use of verbal orders (VO) is discouraged except in

Answer 24

Urgent or emergent situations

Question 25

Any event that is not consistent with the routine, expected care of a patient or standard procedures in place on a health care unit or within an agency

Answer 25

Incident or occurrence

Question 26

A classification used to compare one or more patients to another group of patients

Answer 26

Acuity level

Question 27

Nurses use _____ ratings to determine hours of care and number of staff required for a given group of patients every shift or every 24 hours

Answer 27

Acuity

Question 28

Acuity rating systems are based on

Answer 28

Type and number of nursing interventions required by a patient over a 24 hour period

Question 29

Severity of care

Answer 29

Acuity (Ex: ICU has higher acuity care compared to med-surg units)

Question 30

What is the purpose of an incident report?

Answer 30

Aid in the hospital’s quality improvement program

Question 31

_____ _________ incorporates an interprofessional approach to delivery and documentation of patient care

Answer 31

Case management

Question 32

Interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame

Answer 32

Critical pathways

Question 33

Unexpected outcomes, unmet goals, and interventions not specified within a critical pathway

Answer 33

Variances