health care information management Flashcards
What 3 things is the patient health record?
- Tool for monitoring and evaluating the patient’s health status and response
- Resource for determining regulatory requirement compliance.
- Method for reviewing reimbursement for services rendered.
Which of the following statements about documentation are TRUE? (select all that apply)
a. RNs should use regionally appropriate terms to describe patient care.
b. Patient data is collected throughout all phases of patient care
c. Data is collected only on patient care milestones
d. documentation incorporates the nursing process
b and d
A standardized nursing language that focuses specifically on perioperative nursing and supports evidence-based perioperative nursing practice.
PNDS
A standardized language for perioperative nursing is the…
a. perioperative nurse data storage
b. perioperative nurse data system
c. perioperative nursing documentation system
d. perioperative nurse data set
d
What does structured vocabularies help to define?
helps define data elements that facilitate development of computer databases
What 2 things do structured vocabularies provide?
- provides data to policy makers about outcomes of care provided by perioperative RNs
- Provides quality indicators for outcomes research
What does structured vocabularies allow?
allows comparison of costs and performance across local and national units.
What is the patient health record?
it is a legal document
What can clear, accurate documentation provide?
can provide evidence that the standard of care was provided
What can confusing, contradictory documentation increase?
may increase the potential for a lawsuit
True or false; EHRs eliminate documentation errors.
false
True or false; EHR’s require processes for downtimes.
true
True or false; EHR’s allow data sharing between organizations.
true
True or false; EHR’s improve patient care coordination.
true
An informed consent is obtained by the:
- Surgeon or other licensed practitioner who is performing the procedure
- Anesthesiologist or anesthesia provider who is administering anesthesia.
The informed consent must be what?
be witnessed
What may you be asked to do with informed consent?
you may be asked to witness the patient or guardian signing the consent form.
Who is entitled to be a part of the decision-making process?
the patient or legal guardian
What does informed consent include with a patient?
the right to request or refuse treatment
For scheduled procedures, how are consents handled?
the patient typically signs the consent form in the office
For urgent or emergency procedures, how are consents handled?
the patient or guardian may sign in the preoperative care unit.
Amendments, corrections, or addendums to the patient’s record should only be made to?
- to present an accurate description of the care provided or
- to protect the patient’s interest.
True or false; verbal orders should be used only when required by clinical necessity
true
What are 3 documentation standards?
- eliminate trailing zeros in medication doses
- request the surgeon review orders for accuracy
- use standardized names and terms.
these 3 correction methods belong to this documentation?
- place single line through incorrect entry.
- sign and date entry
- provide rationalize in margins or where there is room.
paper
these 3 correction methods belong to this documentation?
- incorporate a versioning function
- automatically date-, time-and author-stamp the correction
- generate a symbol that indicates a change
electronic
When documenting care on the patient’s chart, use what mnemonic?
FACT
What does FACT stand for?
Factual
Accurate
Complete
Timely
True or false; poor documentation increases the chances of a plaintiff win
true
true or false; patient document is not part of the legal record.
false
True or false; accurate documentation is a risk reduction strategy
true
maintaining professional competence will decrease your risk of being involved in a lawsuit
true
Who is responsible for obtaining the informed consent from the patient?
the licensed practitioner
true or false; the informed consent documentation should include risks and benefits associated with proposed intervention.
true
true or false; legal action for privacy infringement can be brought against the individual producing the infringement
true
true or false; patients must consent for their health information to be used for other than treatment, payment, or business purposes
true
true or false; health care facilities must have administrative procedures to protect the privacy and confidentiality of all patient information.
false
What is patient information that should be shared between the preoperative and intraoperative nurses during the hand off?
- Patient identifiers
- Planned procedure
- Operative side/site
- NPO status
- Allergies
- Diagnostic test results
- Current medications
- Blood products available
- Patient mobility issues
- Family contact information
What is patient information that should be shared between the intraop and postop nurses during the hand off?
- Current condition on airway, breathing, and circulation
- Type of anesthesia administered
- Procedure performed
- Any surgical issues/complications and corrective actions taken
- Skin condition
- Pressure injury risk
- Hypothermia status
- Estimated blood loss
- Input and output
- Presence and location of drains, wound packing
What should be documented under dressings?
- ointments
- appliances
- packing description
What should be documented under pneumatic tourniquet?
- times of inflation and deflation
- cuff pressure settings
- systemic reactions to ischemia and repercussion
What should be documented under lasers?
- eye protection
- wavelength
- total energy used
What should be documented under positioning?
- type and location of safety restraints
- type and location of additional padding
- Actions to prevent injury from items that cannot be removed.
A surgeon verbally orders a medication, what should you do first to decrease the risk of a medication error
Read back the order
Management of potential loss of patient care data should be part of what?
EHR downtime protocols.
Which US law guarantees the privacy of individuals receiving health care services and the confidentiality of their health information.
HIPAA
What is true about standing orders?
Surgeons should review their standing orders/preprinted orders for accuracy
What is recommended if you need to make a correction to a paper health care record?
follow your facility’s policies for corrections
What is a benefit of including the perioperative nursing data set in a perioperative documentation format?
it describes patient care using standardized and unambiguous terms.
true or false; documentation cannot be used to align service with reimbursement
false; it can be
What is NOT a risk reduction strategy?
a. using standardized language
b. limiting documentation to a major episode
c. maintaining confidentiality
d. discussing your assignments with your manager
b. limiting documentation to major episodes
Lawsuits may be derived from failure to
a. follow standards of care
b. assess and monitor the patient
c. document accurately
d. all of the above
all of the above
Any corrections to the patient’s record must comply with what?
federal and state regulations, accreditation requirements, national practice guidelines, and facility policy and procedures.
What are 6 points to remember about medication orders/verbal orders?
- Enter verbal orders into the patient chart as soon as possible.
- Use a read-back process to verify verbal orders.
- Record the names and roles of all involved in patient care.
- Eliminate trailing zeros in medication dosages.
- Use standardized names and terms.
- Ensure standing or preprinted orders are reviewed according to your facility’s policy and procedures.
To reduce your risk of a lawsuit what should you maintain (3 things) and know (1 thing)?
• Maintain open, honest, respectful communication with your patients, their family members, colleagues, and other health
care team members
• Maintain confidentiality in the health care setting
• Maintain your competence in nursing
• Know your scope of practice
what are Orders acted on based on the occurrence of a specific indication or symptom?
As needed (PRN) orders
A security measure to establish the validity of an electronic transmission, message, or original source (eg, author) or to verify the authorization of an individual to receive specific information?
authentication
What is authentication used to confirm?
that an individual or system is who or what it claims to be.
What is A change made to the documented patient health information meant to clarify the entry after the document
has been authenticated?
correction
What are periods of time when the clinical information system (ie, electronic health record) is unavailable because of
scheduled maintenance or upgrades or technology failure, power outage, or another unscheduled event?
downtime
What is an EHR?
An electronic record of health-related information for an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff members across more than one health care organization.
What is an EMR?
An electronic record of health-related information for an individual that can be created, gathered, managed,
and consulted by authorized clinicians and staff members within one health care organization.
What is an electronic signature?
The technology-neutral electronic process used to sign (ie, attest) content for authorship and legal responsibility for a section of information
What are guidelines contain recommendations for implementing perioperative patient care based on a
comprehensive appraisal of both research and nonresearch evidence?
guidelines for perioperative practice
The transfer of patient information from one person to another during transitions of care. Synonym: hand off.
hand over
Authoritative statements that define and enumerate the responsibilities for which perioperative nurses are
accountable.
standards of perioperative nursing
A prewritten medication order and specific instructions from the licensed independent practitioner to administer a medication to a person in clearly defined circumstances.
standing order
