TEST 2 - UNIT B - EF - DOCUMENTATION Flashcards
charting by exception (CBE)
Documenting only unexpected or unusual findings.
computerized provider order entry (CPOE)
Allow providers to enter and transmit prescription electronically
electronic health records (EHRs)
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.
FACT
Acronym used to help nurses with proper documentation practices.FACT stands for factual, accurate, complete, and timely.
focus charting
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).
Health Insurance Portability and Accountability Act (HIPAA)
Established by the federal government with the goal of making healthcare more efficient.
health record
A collection of health information and data about an individual client s health.
HIPPA Privacy Rules
Part of HIPAA. Established in 2003, it created regulations that govern EHR records to protect the privacy of healthcare consumers.
PIE model
Type of documentation that omits the plan of care and utilizes flow sheets and progress notes.
problem-oriented medical record (POMR)
Used to create a comprehensive and organized approach among all members of the interdisciplinary team.
source-oriented medical record
Traditional form of documentation, divided into specific sections within the medical record.
telephone prescription
A prescription received over the telephone from a provider when the provider is not physically present.
verbal prescriptions
Prescriptions received from a provider directly, transcribed by licensed personnel, and later cosigned by the provider.
· Documentation is a fundamental part of
providing health care for clients.
· Every encounter and every intervention a client receives should be
documented accurately and completely within the client’s medical record.
Electronic health records have
streamlined communication in health care.
Electronic health records can provide
efficient continuity of care, from a client’s first admission to a health care facility to discharge.
Health records, in any form, are
legal documents.
The various documentation formats support the
standardization of charting practices for clients’ medical records.
Only_________ abbreviations should be used when documenting client care.
approved
The “do not use” abbreviations list identifies abbreviations that are considered
error prone and dangerous.
Both The Joint Commission and the Institute of Safe Medication Practices maintain
updated lists of these DO NOT USE abbreviations.
In accordance with HIPAA regulations, nurses are required to protect clients’ privacy by
maintaining the confidentiality of their health care information.
ANA standards require nurses to
document care accurately and completely.
The ANA provides guidance on documentation so that it is thorough and accurate. However, ANA standards do not
prevent client records from being reviewed during legal proceedings.
The nurse should include that HIPAA is a federal law, so the regulations do not
vary from state to state. However, states might have more specific laws for medical records in addition to HIPAA regulations.
The nurse should include that HIPAA regulations provide for
protection of personal health information and apply in any situation where client information is communicated from one source to another.
each facility can establish rules for
documentation and use of medical records.
Making routine rounds is not an emergency situation. If the facility has a computerized order entry system, the provider should be able to
enter prescriptions from their current location. Otherwise, they must return to the unit.
Telephone prescriptions should be reserved for use only in
emergency situations, because there is a risk for misunderstanding details about the prescription during verbal communication.
An unresponsive client is an emergency, so it is
appropriate for a nurse to receive a telephone prescription in this situation.
Requiring an over-the-counter medication for nausea relief is not an
emergent situation;
telephone prescriptions should be reserved for
emergency situations.
If a client is experiencing hypoxia, a
telephone prescription would be appropriate.
Requiring pain relief is not an
emergent situation;
If a client is experiencing a cardiac arrythmia, a
telephone prescription might be appropriate.
health care professionals who are directly involved in the client’s care, such as admitting or consulting providers, are allowed
access to the client’s records.
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
access to the client’s records.
The client must provide special consent before
their sibling can view the client’s medical records.
the client has the right to
view their own medical record at any time.
The client must provide special consent before their spiritual advisor can
view the client’s medical records.
Institute of Medicine is the agency that
recommended nationwide use of EHRs in 1997. The recommendation was driven by the belief that it would increase safety in client health care.
Department of Veteran Affairs was an early adopter of EHRs during the 1970s, however, this agency did
not advocate for nationwide use of EHRs.
American Hospital Association (AHA) was
not the agency to recommend nationwide EHR use.
However, the AHA released data in 2017 that 96% of non-federal acute facilities in the United States had converted to
EHRs.
The Joint Commission offers guidance to promote___________ _____________including _________ ____________ However, they were not the agency to advocate for nationwide use of EHRs.
client safety,
documentation standards.
Subjective information includes
direct client statements.
Subjective information includes client reports of
activities, such as daily fluid consumption.
Objective data is information
the nurse gathers when collecting data about the client, such as through physical assessment or diagnostic testing.
is ‘ recommend client referral to registered dietician objective or subjective data
neither, entry is part of the plan of care and is not objective data.
“PO” is the abbreviation for
by mouth. It is included in the list of common medical abbreviations. The nurse should plan to administer the morphine by mouth.
“IM” is the abbreviation for
“intramuscularly.” It is included in the list of common medical abbreviations.
per rectum means to
administer the medication rectally. “PO” is the abbreviation for by mouth. It is included in the list of common medical abbreviations.
“IV” is the abbreviation for
intravenously. It is included in the list of common medical abbreviations.
nurses should not access the medical record of any client
outside of their care assignment.
The nurse should plan to inform the group that staff are expected to
chart any care they provide for clients, including obtaining vital signs.
If a nurse is asked to perform a task, such as obtaining vital signs or administering a medication, they are required to
document task completion.
The nurse should plan to inform the group that strong penalties exist for HIPAA violations, which include b
breaching client confidentiality.
Penalties for breaching client confidentiality.
include termination from the facility, imprisonment, loss of professional licensure, or fines.
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
access to the client’s medical record.
CPOE systems help to eliminate errors in care caused by factors such as
inconsistent abbreviations and illegible handwriting.
CPOE can be used for
prescription entry.
Most CPOE systems have safeguards in place to
promote safe medication prescriptions for the client.
CPOE systems allow provider prescriptions to be
transmitted more quickly from one department to another, which can increase the speed of care delivery for clients.
The nurse should identify that the use of CPOE was advocated under the federal
Health Information Technology for Economic and Clinical Health (HITECH) Act in an effort to improve client safety.
problem-oriented medical record uses the
SOAP format to document entries in the client’s progress notes.
nurse should identify that source-oriented medical records have separate areas for information from
various sources, including testing, nurses’ notes, and progress notes.
A problem-oriented medical record uses
progress notes, which promotes information sharing among members of the interdisciplinary team.
Problem-oriented medical records are more _________ than traditional source-oriented medical records. Therefore, problem-oriented medical records are useful in acute care settings.
organized
The nurse should recognize that one benefit of EHRs is that
clients are able to access their health information from various encounters with health care providers.
The nurse should remind the client that their personal information will remain
confidential and will not be entered into a national database.
The nurse should remind the client that they will have a health care record created for
each health event or encounter the client experiences.
While EHRs have been shown to improve the billing and coding process, this is
not the goal of EHRs.
The nurse should instruct the client that the goal of EHRs is to
improve client care delivery and improve overall health.
Synthroid 100 mg PO every morning ac
WRITTEN CORRECTLY OR NOT
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.
Enoxaparin 75 mg SQ bid
WRITTEN CORRECTLY OR NOT
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.
Digoxin 0.25 mg PO qd
WRITTEN CORRECTLY OR NOT
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.”
Metformin 500.0 mg PO with evening meal
WRITTEN CORRECTLY OR NOT
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.”
