Nur1025 - T2 - Ch. 26 - Documentation & Informatics

Front 1

C1. A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note?

1. Avoid rushing when charting an entry.
2. Use correction fluid to remove the entry.
3. Draw a single line through the statement and initial it.
4. Enter only objective and factual information about the pt.

Back 1

4. Enter only objective and factual information about the pt.

Front 2

C2. A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse:

1. Uses SBAR (Situation-Background-Assessmt-Recommendation) as a format when providing the report.
2. Gives a newly ordered medication before entering the order in the patient's medical record.
3. Reads the orders back to the health care provider after receiving them and verifies their accuracy.
4. Asks the preceptor to listen in on the phone conversation.

Back 2

2. Gives a newly ordered medication before entering the order in the patient's medical record.

Front 3

C3. As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the pt's emotional status?

1. The pt has a defiant attitude and is demanding his test results.
2. The pt appears to be upset with his nurse because he wants his test results immediately.
3. The pt is demanding and complains frequently about his doctor.
4. The pt stated that he felt frustrated by the lack of information he received regarding his tests.

Back 3

4. The pt stated that he felt frustrated by the lack of info he received regarding his tests.

Front 4

C4. You are reviewing Health Insurance Portability and Accountability (HIPAA) regulations with your patient during the admission process. The pt states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response?

1. HIPAA allows all hospital staff access to your medical record.
2. HIPAA limits the information that is documented in your medical record.
3. HIPAA provides you with greater control over your personal health care information.
4. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

Back 4

3. HIPAA provides you with greater control over your personal health care information.

Front 5

C5. A pt asks for a copy of her medical record. The best response by the nurse is to:

1. State that only her family may read the record.
2. Indicate that she has the right to read her record.
3. Tell her that she is not allowed to read her record.
4. Explain that only health care workers have access to her record.

Back 5

2. Indicate that she has the right to read her record.

Front 6

C6. Which of the following charting entries is most accurate?1. Pt walked up and down hallway with assistance, tolerated well.
2. Pt up, out of bed, walked down hallway and back to room, tolerated well.
3. Pt up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied pt during the walk.
4. Pt walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.

Back 6

4. Pt walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.

Front 7

C8. On the nursing unit you are able to access a pt's medical record and review the education that other nurses provided to the pt during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system?
1. Information technology
2. Electronic health record
3. Personal health information
4. Administrative information system

Back 7

2. Electronic health record.

Front 8

C9. You are having a hand-off report to another nurse who will be caring for your pt at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply).

1. The pt's name, age, and admitting diagnosis.
2. Allergies to food and medications
3. Your evaluation that the pt is "needy"
4. How much the pt ate for breakfast
5. That the pt's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol.

Back 8

1. 2. and 5.

Front 9

C10. You are supervising a beginning nursing student who is documenting pt care. Which of the following actions requires you to intervene? The nursing student:

1. Documented medication given by another nursing student.
2. Included the date and time of all entries in the chart.
3. Stood with his back against the wall while documenting on the computer.
4. Signed all documentation electronically.

Back 9

1. Documented medication given by another nursing student.

Front 10

C11. A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE?
1. "CPOE reduces transcription errors"
2. CPOE reduces the time necessary for health care providers to write orders.
3. Health care providers can write orders from any computer that has Internet access.
4. CPOE reduces the time nurses use to communicate with health care providers.

Back 10

1. CPOE reduces transcription errors.

Front 11

C12. You are helping to design a new pt discharge teaching sheet that will go home with pts who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet?

1. The new federal laws require that teaching sheets be emailed to pts after they are discharged.
2. You need to use words the pts can understand when writing the directions.
3. The form needs to be given to patients in a sealed envelope to protect their health information.
4. The names of everyone who cared for the pt in the hospital need to be included on the form in case the pt has questions at home.

Back 11

2. You need to use words the pts can understand when writing the directions.

Front 12

C13.A nurse caring for a pt on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this pt is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system?
1. Electronic health record
2. Clinical documentation
3. Clinical decision support system
4. Computerized physician order entry

Back 12

3. Clinical decision support system

Front 13

C14. While reviewing the pulmonary section of a pt's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the pt's respiratory status in the nurse's notes. The most likely reason for this is because:
1. The nurses forgot to document on the pulmonary system.
2. The nurses were charting by exception.
3. The computer is not working correctly.
4. The physician does not have authorization to view the nursing assessment.

Back 13

2. The nurses were charting by exception.

Front 14

C15. What is an appropriate way for a nurse to dispose of printed patient information?
1. Rip several times and place in a standard trash can
2. Place in the pt's paper-based chart
3. Place in a secure canister marked for shredding
4. Burn the documents

Back 14

3. Place in a secure canister marked for shredding.

Front 15

W1

Documentation?

Back 15

Anything written or printed that the nurse relies on as record or proof of pt actions and activities.

Front 16

W2. According to HIPAA to eliminate barriers that could delay care, providers are: (2 points)

Back 16

1. Providers are required to notify pts of their privacy policy and make a reasonable effort to get written acknowledgment of this notification.
2. HIPAA requires that disclosure or requests regarding health information are limited to the minimum necessary.

Front 17

W3. The standards of documentation by the Joint Commission require:

Back 17

Documentation within the context of the nursing process, AND evidence of patient and family teaching and discharge planning.

Front 18

w4. Re: Purposes of a record

"Communication"

Back 18

Means by which pt needs and progress, individual therapies, pt education, and discharge planning are conveyed to others in the health care team.

Front 19

w5. Re: Purposes of a records

"Legal documentation"

Back 19

Describes exactly what happens to the pt and must follow agency standards

Front 20

w6. Re: Purposes of a records

"Diagnostic-related groups" (DRGs)

Back 20

Classification system based on pt's medical diagnoses that supports reimbursement.

Front 21

w7. Re: Purposes of a records

"Education"

Back 21

Learning the nature of an illness and the individual pt's responses

Front 22

w8. Re: Purposes of a records

"Research"

Back 22

Gathering of statistical data of clinical disorders, complications, therapies, recovery, and deaths.

Front 23

w9. Re: Purposes of a record

"Auditing"

Back 23

Objective, ongoing reviews to determine the degree to which quality improvement standards are met.

Front 24

w10. Re: Guidelines for Quality Documentation & Reporting

Explain "Factual."

Back 24

Contains descriptive, objective, information about what a nurse sees, hears, feels, and smells.

Front 25

w11. Re: Guidelines for Quality Documentation & Reporting

Explain "Accurate."

Back 25

Record uses exact measurements, contains concise data, contains only approved abbreviations, uses correct spelling, and identifies the date and caregiver.

Front 26

w12. Re: Guidelines for Quality Documentation & Reporting

Explain "Complete."

Back 26

Contains all appropriate and essential information.

Front 27

w13. Re: Guidelines for Quality Documentation & Reporting

Explain "Current."

Back 27

Contain timely entries with immediate documentation of information as it is collected from the pt.

Front 28

w14. Re: Guidelines for Quality Documentation & Reporting

Explain "Organized."

Back 28

Communication information in a logical order.

Front 29

w15. Narrative.

Back 29

Story-like format that has the tendency to have repetitious information and be time consuming.

Front 30

w16. Problem-oriented medical record (POMR)

Back 30

Database, problem list, care plan, and progress notes.

Front 31

w17. SOAP

Back 31

Subjective, objective, assessment, and plan

Front 32

w18. SOAPIE

Back 32

SOAP with intervention and evaluation added

Front 33

w19. PIE

Back 33

Problem, intervention, and evaluation with a nursing origin.

Front 34

w20. Electronic health record (EHR)

Back 34

Electronic record of pt information generated whenever a pt accesses medical care in any health care setting.

Front 35

w21. Source record.

Back 35

Separate section for each discipline.

Front 36

w22. Charting by exception

Back 36

Focuses on deviations from the established norm or abnormal findings; highlights trends and changes.

Front 37

w23. Case management

Back 37

Incorporates a multidisciplinary approach to documenting pt care.

Front 38

w24. Critical pathways

Back 38

Multidisciplinary care plans that include pt problems, key interventions, and expected outcomes.

Front 39

Common Record Keeping Forms
w25. Admission nursing history forms

Back 39

Provides current info that is accessible to all members of the health care team.

Front 40

w26. Flow sheets

Back 40

Has activity, treatment, and nursing care plan sections that organize information for quick reference.

Front 41

w27. Kardex

Back 41

Level is based on the type and number of nursing interventions required over a 24-hour period.

Front 42

w28. Acuity records

Back 42

Preprinted, established guidelines used to care for the pt.

Front 43

w29. Standardized care plans

Back 43

Includes meds, diet, community resources, and follow-up care.

Front 44

w30. Discharge summary forms

Back 44

Provides baseline data to compare with changes in the pt's condition.

Front 45

w31. ID the 9 major areas to include in a hand-off report.

Back 45

1. Provide only essential background
2. Identify the pt's nursing Dx or health care problems and their related causes.
3. Describe objective measurements or observations about condition and responses to the health problem
4. Share significant information about family members.
5. Continuously review the ongoing discharge plan.
6. Relay to staff any significant changes in the way therapies are to be given.
7. Describe instructions given in the teaching plan and the responses to instructions.
8. Evaluate the results of nursing or medical care measures
9. Be clear about priorities to which oncoming staff must attend.

Front 46

w32. List the information that needs to be documented with telephone reports.

Back 46

Nurse includes when the call was made, who made it, who was called, to whom information was given, what information was given, and what info was received.

Front 47

w33. List the guidelines the nurse should follow when receiving telephone orders from health care providers.

Back 47

1. Clearly determine the pt's name, room number, and Dx.
2. Repeat all prescribed orders back to the physician.
3. Use clarification questions.
4. Write TO or VO, including the date and time, name of the pt, and the complete order, and sign the physician name and the nurse.
5. Follow agency policies.
6. The Dr. must co-sign the order within the time frame required by the institution.

Front 48

w34. An incident or occurrence is ______. Give some examples of incidents.

Back 48

- Any event that is not consistent with the routine operation of a health care unit or routine care of a patient.
- Examples include pt falls, needle-stick injuries, a visitor with an illness, medication errors, accidental omission of therapies, and any circumstances that lead to pt injury.

Front 49

w35. Define Health informatics.

Back 49

The application of computer and information science in all biomedical sciences to facilitate acquisition, processing, interpretation, optimal use, and communication.

Front 50

w36. Nursing informatics integrates:

Back 50

Integrates nursing science
comp sci
info sci

to manage and communicate data, information, and knowledge in nursing practice.

Front 51

w37. Identify the two nursing information systems that are available.

Back 51

a. Nursing process, NANDA, NIC, and NOC
b. Protocol or critical pathway

Front 52

w38. Identify the advantages of a nursing information system.

Back 52

1. increased time to spend with pts.
2. Better access to information
3. Enhanced quality of documentation
4. Reduced errors of omission
5. Reduced hospital costs
6. Increased nurse job satisfaction
7. Compliance with requirements of accrediting agencies
8. Development of a common clinical database.

Front 53

w39. The primary purpose of a pt's medical record is to:

1. Provide validation for hospital charges.
2. Satisfy requirements of accreditation agencies
3. Provide the nurse with a defense against malpractice
4. Communicate accurate, timely information about the patient.

Back 53

4. The pt's medical record should be the most current and accurate continuous source of information about the pt's health care status.

Front 54

w40. Which of the following is correctly charted according to the 6 guidelines for quality recording?

1. Was depressed today.
2. Respirations rapid; lung sounds clear.
3. Had a good day. Up and about in room
4. Crying. States she doesn't want visitors to see her like this.

Back 54

4. When recording subj data, document the pt's exact words within quotation marks whenever possible.

Front 55

w41. During a change-of-shift report:
1. Two or more nurses always visit all pts to review their plan of care.
2. The nurse should identify nursing Dx and clarify pt priorities.
3. Nurses should exchange judgments they have made about pt attitudes.
4. Pt information is communicated from a nurse on a sending unit to a nurse on a receiving unit.

Back 55

2. An effective c-o-s report describes each pt's health status and lets staff on the next shift know what care the pts will require.

Front 56

w42. An incident report:
1. A legal claim against a nurse for negligent nursing care.
2. A summary report of all falls occurring on a nursing unit.
3. A report of an event inconsistent with the routine care of a pt.
4. A report of a nurse's behavior submitted to the hospital administration.

Back 56

3. An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a pt.

Front 57

w43. If an error is made while recording, the nurse should:

1. Erase it or scratch it out.
2. Leave a blank space in the note.
3. Draw a single line through the error and initial it.
4. Obtain a new nurse's note and rewrite the entries.

Back 57

3. Do not erase, apply correction fluid, or scratch out errors made while recording; it may appear as if you were attempting to hide information or deface the record.