Documentation, Electronic Health Records, and Reporting

Question 1

Health care documentation is

Answer 1

any written or electronically generated information about a patient that describes the patient, the patient’s health, and the care and services provided, including the dates of care

Question 2

Health care documentation records may be both ______ and ______ written

Answer 2

electronic and paper

Question 3

medical record for each patient that is accessed only by

Answer 3

authorized personnel

Question 4

documintation include

Answer 4

reasons for each patient encounter, including assessments and diagnosis;

the plan of care,

the patient’s progress,

any changes in diagnosis and treatment,

the date, and the identity of the observer

Question 5

medical record is

Answer 5

a document with comprehensive information about a patient’s health care encounter, as well as demographic, administrative, and clinical data.

Question 6

the medical record is considered a _______ document

Answer 6

legal

Question 7

medical record must meet guideline for

Answer 7

completeness
accuracy
timeliness
accessibility
authenticity

Question 8

The record can be used to

Answer 8

assess quality-of-care measures
determine the medical necessity of health care services
support reimbursement claims
protect health care providers patients and others in legal matters

Question 9

The use of paper medical records requires no ______ ______ _______

Answer 9

special technical training

Question 10

. Paper medical records are now rarely used except in cases of

Answer 10

electronic system downtime due to power outages or mass disasters

Question 11

When using paper documentation, nurses are responsible for knowing how to

Answer 11

correctly spell and document events

Question 12

electronic medical record (EMR) is

Answer 12

longitudinal record of health that includes the information from inpatient and outpatient episodes of health care from one or more care settings

Question 13

Health information comprises patient data such as

Answer 13

demographics, assessment findings, flow sheets that include point-of-care results, diagnoses, nursing treatments, and a medication profile listing historical and currently active medication orders

Question 14

Computerized provider order entry (CPOE) allows clinicians to

Answer 14

enter orders in a computer that are sent directly to the appropriate department

Question 15

Decision support in the electronic record may include

Answer 15

medication interaction screening and reminders for preventive health actions, such as vaccinations

Question 16

The electronic record provides

Answer 16

connectivity to enhance communication between all members of the health care team

Question 17

EHR supports administrative processes with more efficient and timely data abstraction for

Answer 17

scheduling, billing, and claims management

Question 18

All healthcare personnel must have a basic level of

Answer 18

computer competency in addition to an understanding of documentation principles

Question 19

Documentation should be

Answer 19

factual, accurate, and nonjudgmental, with proper spelling and grammar. Events should be reported in the order they happened, and documentation should occur as soon as possible after assessment, interventions, condition changes, or evaluation

Question 20

Nursing documentation is guided by the five steps of the nursing process:

Answer 20

assessment, diagnosis, planning, implementation, and evaluation

Question 21

problem-oriented medical record (POMR) integrates

Answer 21

charting from the entire care team in the same section of the record

Question 22

Do-Not-Use Abbreviations are:

Answer 22

U, u (unit)
IU (international unit)
QD, Q.D., qd, q.d. (daily)
QOD, Q.O.D., qod, q.o.d (every other day)
MS, MSO4, and MgSO4
Trailing zero (X.0mg)
Lack of leading zero (.X mg)

Question 23

Problem-Oriented Medical Records Formats

Answer 23

PIE
APIE
SOAP
SOAPIE
SOAPIER
DAR
CBE

Question 24

PIE stands for

Answer 24

Problem, intervention, evaluation

Question 25

APIE stands for

Answer 25

Assessment, problem, intervention, evaluation

Question 26

SOAP stands for

Answer 26

Subjective data, objective data, assessment, plan

Question 27

SOAPIE stands for

Answer 27

Subjective data, objective data, assessment, plan, intervention, evaluation

Question 28

DAR stands for

Answer 28

Data, action, response

Question 29

CBE stands for

Answer 29

Charting by exception

Question 30

SOAPIER stands for

Answer 30

Subjective data, objective data, assessment, plan, intervention, evaluation, revisions to plan

Question 31

Narrative charting is

Answer 31

chronologic, with a baseline recorded on a shift-by-shift basis

Question 32

Narrative charting may stand alone or may be complemented by other tools, such as

Answer 32

flow charts, flow sheets, and checklists

Question 33

Charting by exception (CBE) is

Answer 33

documentation that records only abnormal or significant data

Question 34

Case Management Documentation is focused on

Answer 34

providing and documenting high-quality, cost-effective delivery of patient care

Question 35

The goal of case management is

Answer 35

to achieve realistic and desired patient and family outcomes within appropriate lengths of stay and with appropriate use of resources

Question 36

Flow sheets and checklists within the EHR may be used to

Answer 36

document routine care and observations that are recorded on a regular basis, such as vital signs, medications, and intake and output measurements

Question 37

medication administration record (MAR) is

Answer 37

list of ordered medications, along with dosages, routes, and times of administration, on which the nurse initials medications given or not given

Question 38

If a medication is not given, the nurse should

Answer 38

note the reason on the MAR

Question 39

Documentation in the EHR is a

Answer 39

legal record of patient care

Question 40

The medical record is seen as

Answer 40

most reliable source of information in any legal action related to care

Question 41

Health Insurance Portability and Accountability Act (HIPAA), originally passed in 1996, created standards for

Answer 41

the protection of personal health information, whether conveyed orally or recorded in any form or medium

Question 42

confidentiality in health record means

Answer 42

being entrusted with private patient information

Question 43

hand-off is

Answer 43

The real-time process of passing patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety

Question 44

Hand-offs can be

Answer 44

oral, as in a face-to-face meeting or telephone communication, or they can be written, recorded, or printed from the EHR

Question 45

sentinel event is

Answer 45

safety occurrence that affects a patient and causes death, serious permanent or temporary injury, or requires interventions to sustain life

Question 46

SBAR stands for

Answer 46

situation, background, assessment, and recommendation