health care information management

Question 1

What 3 things is the patient health record?

Answer 1

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.

Question 2

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

Answer 2

b and d

Question 3

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

Answer 3

PNDS

Question 4

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

Answer 4

d

Question 5

What does structured vocabularies help to define?

Answer 5

helps define data elements that facilitate development of computer databases

Question 6

What 2 things do structured vocabularies provide?

Answer 6

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

Question 7

What does structured vocabularies allow?

Answer 7

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

Question 8

What is the patient health record?

Answer 8

it is a legal document

Question 9

What can clear, accurate documentation provide?

Answer 9

can provide evidence that the standard of care was provided

Question 10

What can confusing, contradictory documentation increase?

Answer 10

may increase the potential for a lawsuit

Question 11

True or false; EHRs eliminate documentation errors.

Answer 11

false

Question 12

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

Answer 12

true

Question 13

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

Answer 13

true

Question 14

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

Answer 14

true

Question 15

An informed consent is obtained by the:

Answer 15

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

Question 16

The informed consent must be what?

Answer 16

be witnessed

Question 17

What may you be asked to do with informed consent?

Answer 17

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

Question 18

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

Answer 18

the patient or legal guardian

Question 19

What does informed consent include with a patient?

Answer 19

the right to request or refuse treatment

Question 20

For scheduled procedures, how are consents handled?

Answer 20

the patient typically signs the consent form in the office

Question 21

For urgent or emergency procedures, how are consents handled?

Answer 21

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

Question 22

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

Answer 22

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

Question 23

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

Answer 23

true

Question 24

What are 3 documentation standards?

Answer 24

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

Question 25

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.

Answer 25

paper

Question 26

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

Answer 26

electronic

Question 27

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

Answer 27

FACT

Question 28

What does FACT stand for?

Answer 28

Factual Accurate Complete Timely

Question 29

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

Answer 29

true

Question 30

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

Answer 30

false

Question 31

True or false; accurate documentation is a risk reduction strategy

Answer 31

true

Question 32

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

Answer 32

true

Question 33

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

Answer 33

the licensed practitioner

Question 34

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

Answer 34

true

Question 35

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

Answer 35

true

Question 36

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

Answer 36

true

Question 37

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

Answer 37

false

Question 38

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

Answer 38

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

Question 39

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

Answer 39

* 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

Question 40

What should be documented under dressings?

Answer 40

1. ointments 2. appliances 3. packing description

Question 41

What should be documented under pneumatic tourniquet?

Answer 41

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

Question 42

What should be documented under lasers?

Answer 42

1. eye protection 2. wavelength 3. total energy used

Question 43

What should be documented under positioning?

Answer 43

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.

Question 44

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

Answer 44

Read back the order

Question 45

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

Answer 45

EHR downtime protocols.

Question 46

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

Answer 46

HIPAA

Question 47

What is true about standing orders?

Answer 47

Surgeons should review their standing orders/preprinted orders for accuracy

Question 48

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

Answer 48

follow your facility's policies for corrections

Question 49

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

Answer 49

it describes patient care using standardized and unambiguous terms.

Question 50

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

Answer 50

false; it can be

Question 51

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

Answer 51

b. limiting documentation to major episodes

Question 52

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

Answer 52

all of the above

Question 53

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

Answer 53

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

Question 54

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

Answer 54

* 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.

Question 55

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

Answer 55

• 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

Question 56

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

Answer 56

As needed (PRN) orders

Question 57

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?

Answer 57

authentication

Question 58

What is authentication used to confirm?

Answer 58

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

Question 59

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

Answer 59

correction

Question 60

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?

Answer 60

downtime

Question 61

What is an EHR?

Answer 61

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.

Question 62

What is an EMR?

Answer 62

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.

Question 63

What is an electronic signature?

Answer 63

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

Question 64

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

Answer 64

guidelines for perioperative practice

Question 65

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

Answer 65

hand over

Question 66

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

Answer 66

standards of perioperative nursing

Question 67

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

Answer 67

standing order