TEST 2 - UNIT B - EF - DOCUMENTATION

Question 1

charting by exception (CBE)

Answer 1

Documenting only unexpected or unusual findings.

Question 2

computerized provider order entry (CPOE)

Answer 2

Allow providers to enter and transmit prescription electronically

Question 3

electronic health records (EHRs)

Answer 3

Systemic, digitized documentation system used to improve medical records. A computerized, real-time form of a client’s paper chart that can be shared between members of the interprofessional team; includes information such as the medical history, diagnosis, allergies, and diagnostic testing results.

Question 4

FACT

Answer 4

Acronym used to help nurses with proper documentation practices.FACT stands for factual, accurate, complete, and timely.

Question 5

focus charting

Answer 5

Centers on specific health care problems and the change in condition, client events and concerns. Three items must be documented which are data, action and response (DAR).

Question 6

Health Insurance Portability and Accountability Act (HIPAA)

Answer 6

Established by the federal government with the goal of making healthcare more efficient.

Question 7

health record

Answer 7

A collection of health information and data about an individual client s health.

Question 8

HIPPA Privacy Rules

Answer 8

Part of HIPAA. Established in 2003, it created regulations that govern EHR records to protect the privacy of healthcare consumers.

Question 9

PIE model

Answer 9

Type of documentation that omits the plan of care and utilizes flow sheets and progress notes.

Question 10

problem-oriented medical record (POMR)

Answer 10

Used to create a comprehensive and organized approach among all members of the interdisciplinary team.

Question 11

source-oriented medical record

Answer 11

Traditional form of documentation, divided into specific sections within the medical record.

Question 12

telephone prescription

Answer 12

A prescription received over the telephone from a provider when the provider is not physically present.

Question 13

verbal prescriptions

Answer 13

Prescriptions received from a provider directly, transcribed by licensed personnel, and later cosigned by the provider.

Question 14

· Documentation is a fundamental part of

Answer 14

providing health care for clients.

Question 15

· Every encounter and every intervention a client receives should be

Answer 15

documented accurately and completely within the client’s medical record.

Question 16

Electronic health records have

Answer 16

streamlined communication in health care.

Question 17

Electronic health records can provide

Answer 17

efficient continuity of care, from a client’s first admission to a health care facility to discharge.

Question 18

Health records, in any form, are

Answer 18

legal documents.

Question 19

The various documentation formats support the

Answer 19

standardization of charting practices for clients’ medical records.

Question 20

Only_________ abbreviations should be used when documenting client care.

Answer 20

approved

Question 21

The “do not use” abbreviations list identifies abbreviations that are considered

Answer 21

error prone and dangerous.

Question 22

Both The Joint Commission and the Institute of Safe Medication Practices maintain

Answer 22

updated lists of these DO NOT USE abbreviations.

Question 23

In accordance with HIPAA regulations, nurses are required to protect clients’ privacy by

Answer 23

maintaining the confidentiality of their health care information.

Question 24

ANA standards require nurses to

Answer 24

document care accurately and completely.

Question 25

The ANA provides guidance on documentation so that it is thorough and accurate. However, ANA standards do not

Answer 25

prevent client records from being reviewed during legal proceedings.

Question 26

The nurse should include that HIPAA is a federal law, so the regulations do not

Answer 26

vary from state to state. However, states might have more specific laws for medical records in addition to HIPAA regulations.

Question 27

The nurse should include that HIPAA regulations provide for

Answer 27

protection of personal health information and apply in any situation where client information is communicated from one source to another.

Question 28

each facility can establish rules for

Answer 28

documentation and use of medical records.

Question 29

Making routine rounds is not an emergency situation. If the facility has a computerized order entry system, the provider should be able to

Answer 29

enter prescriptions from their current location. Otherwise, they must return to the unit.

Question 30

Telephone prescriptions should be reserved for use only in

Answer 30

emergency situations, because there is a risk for misunderstanding details about the prescription during verbal communication.

Question 31

An unresponsive client is an emergency, so it is

Answer 31

appropriate for a nurse to receive a telephone prescription in this situation.

Question 32

Requiring an over-the-counter medication for nausea relief is not an

Answer 32

emergent situation;

Question 33

telephone prescriptions should be reserved for

Answer 33

emergency situations.

Question 34

If a client is experiencing hypoxia, a

Answer 34

telephone prescription would be appropriate.

Question 35

Requiring pain relief is not an

Answer 35

emergent situation;

Question 36

If a client is experiencing a cardiac arrythmia, a

Answer 36

telephone prescription might be appropriate.

Question 37

health care professionals who are directly involved in the client’s care, such as admitting or consulting providers, are allowed

Answer 37

access to the client’s records.

Question 38

health care professionals who are directly involved in the client’s care, such as those who supervise client care (charge nurse, nursing supervisor), are allowed

Answer 38

access to the client’s records.

Question 39

The client must provide special consent before

Answer 39

their sibling can view the client’s medical records.

Question 40

the client has the right to

Answer 40

view their own medical record at any time.

Question 41

The client must provide special consent before their spiritual advisor can

Answer 41

view the client’s medical records.

Question 42

Institute of Medicine is the agency that

Answer 42

recommended nationwide use of EHRs in 1997. The recommendation was driven by the belief that it would increase safety in client health care.

Question 43

Department of Veteran Affairs was an early adopter of EHRs during the 1970s, however, this agency did

Answer 43

not advocate for nationwide use of EHRs.

Question 44

American Hospital Association (AHA) was

Answer 44

not the agency to recommend nationwide EHR use.

Question 45

However, the AHA released data in 2017 that 96% of non-federal acute facilities in the United States had converted to

Answer 45

EHRs.

Question 46

The Joint Commission offers guidance to promote___________ _____________including _________ ____________ However, they were not the agency to advocate for nationwide use of EHRs.

Answer 46

client safety,
documentation standards.

Question 47

Subjective information includes

Answer 47

direct client statements.

Question 48

Subjective information includes client reports of

Answer 48

activities, such as daily fluid consumption.

Question 49

Objective data is information

Answer 49

the nurse gathers when collecting data about the client, such as through physical assessment or diagnostic testing.

Question 50

is ‘ recommend client referral to registered dietician objective or subjective data

Answer 50

neither, entry is part of the plan of care and is not objective data.

Question 51

“PO” is the abbreviation for

Answer 51

by mouth. It is included in the list of common medical abbreviations. The nurse should plan to administer the morphine by mouth.

Question 52

“IM” is the abbreviation for

Answer 52

“intramuscularly.” It is included in the list of common medical abbreviations.

Question 53

per rectum means to

Answer 53

administer the medication rectally. “PO” is the abbreviation for by mouth. It is included in the list of common medical abbreviations.

Question 54

“IV” is the abbreviation for

Answer 54

intravenously. It is included in the list of common medical abbreviations.

Question 55

nurses should not access the medical record of any client

Answer 55

outside of their care assignment.

Question 56

The nurse should plan to inform the group that staff are expected to

Answer 56

chart any care they provide for clients, including obtaining vital signs.

Question 57

If a nurse is asked to perform a task, such as obtaining vital signs or administering a medication, they are required to

Answer 57

document task completion.

Question 58

The nurse should plan to inform the group that strong penalties exist for HIPAA violations, which include b

Answer 58

breaching client confidentiality.

Question 59

Penalties for breaching client confidentiality.

Answer 59

include termination from the facility, imprisonment, loss of professional licensure, or fines.

Question 60

The nurse should plan to inform the group that only health care professionals who are assigned to assist with the care of a client’s current health care needs are allowed

Answer 60

access to the client’s medical record.

Question 61

CPOE systems help to eliminate errors in care caused by factors such as

Answer 61

inconsistent abbreviations and illegible handwriting.

Question 62

CPOE can be used for

Answer 62

prescription entry.

Question 63

Most CPOE systems have safeguards in place to

Answer 63

promote safe medication prescriptions for the client.

Question 64

CPOE systems allow provider prescriptions to be

Answer 64

transmitted more quickly from one department to another, which can increase the speed of care delivery for clients.

Question 65

The nurse should identify that the use of CPOE was advocated under the federal

Answer 65

Health Information Technology for Economic and Clinical Health (HITECH) Act in an effort to improve client safety.

Question 66

problem-oriented medical record uses the

Answer 66

SOAP format to document entries in the client’s progress notes.

Question 67

nurse should identify that source-oriented medical records have separate areas for information from

Answer 67

various sources, including testing, nurses’ notes, and progress notes.

Question 68

A problem-oriented medical record uses

Answer 68

progress notes, which promotes information sharing among members of the interdisciplinary team.

Question 69

Problem-oriented medical records are more _________ than traditional source-oriented medical records. Therefore, problem-oriented medical records are useful in acute care settings.

Answer 69

organized

Question 70

The nurse should recognize that one benefit of EHRs is that

Answer 70

clients are able to access their health information from various encounters with health care providers.

Question 71

The nurse should remind the client that their personal information will remain

Answer 71

confidential and will not be entered into a national database.

Question 72

The nurse should remind the client that they will have a health care record created for

Answer 72

each health event or encounter the client experiences.

Question 73

While EHRs have been shown to improve the billing and coding process, this is

Answer 73

not the goal of EHRs.

Question 74

The nurse should instruct the client that the goal of EHRs is to

Answer 74

improve client care delivery and improve overall health.

Question 75

Synthroid 100 mg PO every morning ac
WRITTEN CORRECTLY OR NOT

Answer 75

This medication entry is written correctly because both PO and ac are commonly used abbreviations and do not appear on The Joint Commission’s Do Not Use list.

Question 76

Enoxaparin 75 mg SQ bid
WRITTEN CORRECTLY OR NOT

Answer 76

This medication entry is written incorrectly because SQ appears on The Joint Commission’s Do Not Use list. The abbreviation SQ should be written as “subcut” or completely spelled out as “subcutaneously.” The abbreviation bid is an acceptable and commonly used abbreviation.

Question 77

Digoxin 0.25 mg PO qd
WRITTEN CORRECTLY OR NOT

Answer 77

This medication entry is written incorrectly because qd appears on The Joint Commission’s Do Not Use list. The abbreviation qd should be written as “daily.”

Question 78

Metformin 500.0 mg PO with evening meal
WRITTEN CORRECTLY OR NOT

Answer 78

This medication entry is written incorrectly because the dose has a trailing zero which appears on The Joint Commission’s Do Not Use list. The dose should be written as “500 mg.”