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AORN Periop class > health care information management > Flashcards

health care information management Flashcards

1
Q

What 3 things is the patient health record?

A
  1. Tool for monitoring and evaluating the patient’s health status and response
  2. Resource for determining regulatory requirement compliance.
  3. Method for reviewing reimbursement for services rendered.
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2
Q

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

A

b and d

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3
Q

A standardized nursing language that focuses specifically on perioperative nursing and supports evidence-based perioperative nursing practice.

A

PNDS

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4
Q

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

A

d

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5
Q

What does structured vocabularies help to define?

A

helps define data elements that facilitate development of computer databases

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6
Q

What 2 things do structured vocabularies provide?

A
  1. provides data to policy makers about outcomes of care provided by perioperative RNs
  2. Provides quality indicators for outcomes research
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7
Q

What does structured vocabularies allow?

A

allows comparison of costs and performance across local and national units.

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8
Q

What is the patient health record?

A

it is a legal document

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9
Q

What can clear, accurate documentation provide?

A

can provide evidence that the standard of care was provided

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10
Q

What can confusing, contradictory documentation increase?

A

may increase the potential for a lawsuit

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11
Q

True or false; EHRs eliminate documentation errors.

A

false

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12
Q

True or false; EHR’s require processes for downtimes.

A

true

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13
Q

True or false; EHR’s allow data sharing between organizations.

A

true

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14
Q

True or false; EHR’s improve patient care coordination.

A

true

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15
Q

An informed consent is obtained by the:

A
  1. Surgeon or other licensed practitioner who is performing the procedure
  2. Anesthesiologist or anesthesia provider who is administering anesthesia.
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16
Q

The informed consent must be what?

A

be witnessed

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17
Q

What may you be asked to do with informed consent?

A

you may be asked to witness the patient or guardian signing the consent form.

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18
Q

Who is entitled to be a part of the decision-making process?

A

the patient or legal guardian

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19
Q

What does informed consent include with a patient?

A

the right to request or refuse treatment

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20
Q

For scheduled procedures, how are consents handled?

A

the patient typically signs the consent form in the office

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21
Q

For urgent or emergency procedures, how are consents handled?

A

the patient or guardian may sign in the preoperative care unit.

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22
Q

Amendments, corrections, or addendums to the patient’s record should only be made to?

A
  1. to present an accurate description of the care provided or
  2. to protect the patient’s interest.
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23
Q

True or false; verbal orders should be used only when required by clinical necessity

A

true

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24
Q

What are 3 documentation standards?

A
  1. eliminate trailing zeros in medication doses
  2. request the surgeon review orders for accuracy
  3. use standardized names and terms.
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25
Q

these 3 correction methods belong to this documentation?

  1. place single line through incorrect entry.
  2. sign and date entry
  3. provide rationalize in margins or where there is room.
A

paper

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26
Q

these 3 correction methods belong to this documentation?

  1. incorporate a versioning function
  2. automatically date-, time-and author-stamp the correction
  3. generate a symbol that indicates a change
A

electronic

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27
Q

When documenting care on the patient’s chart, use what mnemonic?

A

FACT

28
Q

What does FACT stand for?

A

Factual
Accurate
Complete
Timely

29
Q

True or false; poor documentation increases the chances of a plaintiff win

A

true

30
Q

true or false; patient document is not part of the legal record.

A

false

31
Q

True or false; accurate documentation is a risk reduction strategy

A

true

32
Q

maintaining professional competence will decrease your risk of being involved in a lawsuit

A

true

33
Q

Who is responsible for obtaining the informed consent from the patient?

A

the licensed practitioner

34
Q

true or false; the informed consent documentation should include risks and benefits associated with proposed intervention.

A

true

35
Q

true or false; legal action for privacy infringement can be brought against the individual producing the infringement

A

true

36
Q

true or false; patients must consent for their health information to be used for other than treatment, payment, or business purposes

A

true

37
Q

true or false; health care facilities must have administrative procedures to protect the privacy and confidentiality of all patient information.

A

false

38
Q

What is patient information that should be shared between the preoperative and intraoperative nurses during the hand off?

A
  • Patient identifiers
  • Planned procedure
  • Operative side/site
  • NPO status
  • Allergies
  • Diagnostic test results
  • Current medications
  • Blood products available
  • Patient mobility issues
  • Family contact information
39
Q

What is patient information that should be shared between the intraop and postop nurses during the hand off?

A
  • 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
40
Q

What should be documented under dressings?

A
  1. ointments
  2. appliances
  3. packing description
41
Q

What should be documented under pneumatic tourniquet?

A
  1. times of inflation and deflation
  2. cuff pressure settings
  3. systemic reactions to ischemia and repercussion
42
Q

What should be documented under lasers?

A
  1. eye protection
  2. wavelength
  3. total energy used
43
Q

What should be documented under positioning?

A
  1. type and location of safety restraints
  2. type and location of additional padding
  3. Actions to prevent injury from items that cannot be removed.
44
Q

A surgeon verbally orders a medication, what should you do first to decrease the risk of a medication error

A

Read back the order

45
Q

Management of potential loss of patient care data should be part of what?

A

EHR downtime protocols.

46
Q

Which US law guarantees the privacy of individuals receiving health care services and the confidentiality of their health information.

A

HIPAA

47
Q

What is true about standing orders?

A

Surgeons should review their standing orders/preprinted orders for accuracy

48
Q

What is recommended if you need to make a correction to a paper health care record?

A

follow your facility’s policies for corrections

49
Q

What is a benefit of including the perioperative nursing data set in a perioperative documentation format?

A

it describes patient care using standardized and unambiguous terms.

50
Q

true or false; documentation cannot be used to align service with reimbursement

A

false; it can be

51
Q

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

A

b. limiting documentation to major episodes

52
Q

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

A

all of the above

53
Q

Any corrections to the patient’s record must comply with what?

A

federal and state regulations, accreditation requirements, national practice guidelines, and facility policy and procedures.

54
Q

What are 6 points to remember about medication orders/verbal orders?

A
  • 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.
55
Q

To reduce your risk of a lawsuit what should you maintain (3 things) and know (1 thing)?

A

• 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

56
Q

what are Orders acted on based on the occurrence of a specific indication or symptom?

A

As needed (PRN) orders

57
Q

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?

A

authentication

58
Q

What is authentication used to confirm?

A

that an individual or system is who or what it claims to be.

59
Q

What is A change made to the documented patient health information meant to clarify the entry after the document
has been authenticated?

A

correction

60
Q

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?

A

downtime

61
Q

What is an EHR?

A

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.

62
Q

What is an EMR?

A

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.

63
Q

What is an electronic signature?

A

The technology-neutral electronic process used to sign (ie, attest) content for authorship and legal responsibility for a section of information

64
Q

What are guidelines contain recommendations for implementing perioperative patient care based on a
comprehensive appraisal of both research and nonresearch evidence?

A

guidelines for perioperative practice

65
Q

The transfer of patient information from one person to another during transitions of care. Synonym: hand off.

A

hand over

66
Q

Authoritative statements that define and enumerate the responsibilities for which perioperative nurses are
accountable.

A

standards of perioperative nursing

67
Q

A prewritten medication order and specific instructions from the licensed independent practitioner to administer a medication to a person in clearly defined circumstances.

A

standing order

AORN Periop class (23 decks)

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