Ch. 26 Documentation and Informatics
A group of nurses are discussing the advantages of using computerized provider order entry (CPOE). Which statements indicate that the nurses understand the major advantage of using CPOE? "CPOE reduces transcription errors." "CPOE reduces the time necessary for healthcare providers to write orders." "Healthcare providers can write orders from any computer that has Internet access." "CPOE reduces the time nurses use to communicate with healthcare providers."
"CPOE reduces transcription errors." CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly; therefore, CPOE reduces transcription errors. CPOE does not necessarily reduce the amount of time it would take a healthcare provider to write a safe and accurate order. CPOE should not decrease communication within the interprofessional team. Orders should only be written on secure networks to ensure patient privacy.
DAR note
A DAR note organizes information as data (D) collected about the patient's problems, the action (A) initiated, and the patient's response (R) to the actions. Example: D: Patient grimacing. Holding hand at surgical site. States pain at a level of 8 of 10. A: Patient given morphine at 0930 per order and repositioned for comfort. R: Patient reported a 3 of 10 pain level 20 minutes after morphine was administered.
PIE note structures
A PIE note structures information by reporting the problem (P), intervention (I), and evaluation (E). Example: P: Acute pain rated by postsurgical patient as 8 of 10. I: Morphine given at 0930 per order for pain relief. Patient repositioned for comfort. E: Patient reported a 3 of 10 pain level 20 minutes after morphine was administered.
SOAP note
A SOAP note organizes information into subjective data (S), objective data (O), assessment (A), and plan (P). The format is sometimes expanded to a SOAPIE note, which includes the actual interventions (I) and an evaluation (E) of intervention outcomes. Another form of the SOAP note is the SOAPIER note, which adds revision (R) of the plan of care as necessary to meet the follow-up needs of the patient. Questions to ask to create a SOAPIER note: S: What do the patient and others tell you? O: What are the physical examination results, the relevant vital signs, or the results of other pertinent tests? A: What is the patient's current status? P: What are the necessary interventions? I: What treatments did the nurse provide? E: What are the patient outcomes after each intervention? R: Does the plan stay the same? What changes are needed to the care plan?
High-quality nursing documentation is characterized by which important elements? Select all that apply. Accessibility of documentation Relevance of documentation Conciseness of documentation Timeliness of documentation Thoughtfulness of documentation Literary value of documentation
Accessibility of documentation Relevance of documentation Timeliness of documentation Thoughtfulness of documentation
A hospital unit maintains documentation in the form of a problem-oriented medical record (POMR). The nurse notices that a patient reports symptoms of acid reflux. On further assessment, the nurse finds that the patient has fully recovered from typhoid. Where and how does the nurse update the record? Add the new problem to the problem list of the patient. Highlight typhoid and add the date of recovery. Highlight reflux and add the date of the occurrence of the sign. Remove the old progress note and add a new one with updates. Add a new admission assessment along with the existing records.
Add the new problem to the problem list of the patient. Highlight typhoid and add the date of recovery. Using the problem-oriented medical record (POMR) method of documentation, four major sections are maintained, namely the database, problem list, care plan, and progress notes. The problem list contains all the patient's problems in chronological order. The information about the new sign and the recovery from the previous illness is recorded in the problem list in the following manner: The new problem (acid reflux) is added to the problem list, the solved problem (typhoid) is highlighted, and the date of resolution is added. New problems are not to be highlighted. Progress notes should not be removed from the medical record. A new admission assessment is not required for a new problem when the patient is still in the hospital.
ANTICipate model
Administrative data Name, record number, location New clinical information to be updated Real-time information Tasks to be performed Clear explanation of tasks Illness severity Information about illness severity Contingency Plans for changes in clinical status
The nurse is recording specific demographic information about a patient in a hospital. Which section of the traditional source record does the nurse use to record this information? Nurses' notes Admission sheet Graphic sheet and flow sheet Nurse's admission assessment
Admission sheet Demographic information includes the legal name, identification number, gender, age, birth date, marital status, and occupation of the patient. Demographic information also includes health insurance, nearest relative to notify in an emergency, religious preference, name of attending physician, and date and time of patient's admission. This information is included on the admission sheet section. Nurses' notes include information about the assessment, nursing diagnosis, planning, implementation, and evaluation of patient care. Information about repeated observations and measurements such as vital signs, daily weights, and intakes and outputs are included under the graphic sheet and flow sheet section. The nurse's admission assessment section includes a summary of the patient's nursing history and physical examination.
How can standardized nursing terminology directly enhance patient care? Allows health care providers in different departments to better understand each other's reports Allows the nurse to articulate pay raise requests to supervisors Makes courses available to improve bedside manner Improves the medical vocabulary of nurses
Allows health care providers in different departments to better understand each other's reports
APIE note structures
An APIE note adds assessment (A), combining subjective and objective assessment data in the PIE format. Example: A: Patient holding hand over surgical site and grimacing while reporting pain at a level of 8 of 10 on the pain scale. P: Patient is experiencing acute post-surgical pain. I: Morphine given at 0930 per order for pain relief. Patient repositioned for comfort. E: Patient reported a 3 of 10 pain level 20 minutes after morphine was administered.
Criteria for evaluating websites providing health care information include:
Authority Who is the sponsor or publisher? Is this a personal page? Where does it come from? Is the author or organization listed? What are the author's credentials? Purpose Does the site inform? Explain? Share? Disclose? Sell? What is the intended audience? Coverage Are citations correct? Is there a balance of text and images? Currency When was the site created? How often is it updated? Objectivity What are the goals and objectives of the site? Is there evidence of bias? Is bias explicit or hidden? Accuracy Are there footnotes or links to information sources? Verification Can the information be found in other sources?
In what ways has the use of informatics in health care benefitted research? Select all that apply. Computer programs can analyze data to identify trends, allowing meaningful organization of information for research. Research methods have advanced to require fewer subjects to achieve meaningful research results. Complete patient electronic health records are released regularly for public research use. Comparisons of nursing care data can be easily used to support evidence-based nursing. Digital health care data is an accessible source of information easily utilized in research.
Computer programs can analyze data to identify trends, allowing meaningful organization of information for research. Comparisons of nursing care data can be easily used to support evidence-based nursing. Digital health care data is an accessible source of information easily utilized in research.
Which two major fields of study are integrated in nursing informatics? Information science and pharmaceutics Computer programming and computer science Biomedical engineering and information science Computer science and information science
Computer science and information science Nursing informatics integrates nursing, computer, and information science for the management and communication of data, information, knowledge, and wisdom.
Order concepts of knowledge in informatics from shallow to applied.
Data Information Knowledge Wisdom
What does the use of information technology in health care enable? Select all that apply. Data retrieval Data suppression Data capture Data marketing Data storage
Data retrieval Data capture Data storage
Which information should be recorded for every entry in the medical record? Select all that apply. Date Time Day of the week Patient's signature Nurse's signature
Date Time Nurse's signature
Lesson Assessment Performance 33% CORRECT Hang in there! Let's review your results Overview Incorrect Correct Question 2 of 6 Which information should be included in an ANTICipate hand-off report? Previous patient hospitalizations Previous patient hospitalizations are not included in the ANTICipate model. Correct Details about the patient's intubation procedure The ANTICipate model should include information about tasks performed by the provider. Correct Planned treatment if the patient's condition worsens The ANTICipate model should include information about contingency plans. Correct Change in the patient's status from "critical" to "serious" The ANTICipate model should include information about changes in the patient's clinical status. Incorrect Information about the patient's next of kin Information about the patient's next of kin is not included in the ANTICipate model.
Details about the patient's intubation procedure The ANTICipate model should include information about tasks performed by the provider. Correct Planned treatment if the patient's condition worsens The ANTICipate model should include information about contingency plans. Correct Change in the patient's status from "critical" to "serious" The ANTICipate model should include information about changes in the patient's clinical status. Incorrect
In which section of the EMR would a nurse find laboratory test values? Order-entry system Decision support Diagnostic results Patient demographics
Diagnostic results
Which characteristic distinguishes the charting by exception documentation format? Documentation of only unexpected or clinically significant findings Inclusion of all past data, but no present data Documentation of all care except interventions still in progress Documentation of only expected findings
Documentation of only unexpected or clinically significant findings
Which statements describe problem-oriented medical records and documentation? Select all that apply. Documentation usually follows a preset framework for organization. The medical record integrates charting from most or all health care professions in the same section. The medical record separates charting from medicine, nursing, physical therapy, nutrition, and other professions into various sections. Documentation is narrative. Documentation is strategically organized for easy reference by multiple professions.
Documentation usually follows a preset framework for organization. The medical record integrates charting from most or all health care professions in the same section. Documentation is strategically organized for easy reference by multiple professions.
Which aspect(s) of an unexpected event involving administration of the wrong medication should the nurse document in the incident report? Dosage of the medication that the patient was administered The dosage of medication that the patient was administered would be recorded in the report. Nurse's suspicion that the patient lied to obtain a different medication Suspicions should not be included in the incident report, only verifiable facts. Correct Date and time of the incident The date and time of the incident would be included in the incident report. Correct Name of the nurse who administered the medication The names of all parties present at the time of the incident would be included in the incident report. Correct Action taken in response to the incident The action taken in response to the incident or to remedy the situation would be included in the incident report.
Dosage of the medication that the patient was administered The dosage of medication that the patient was administered would be recorded in the report. Date and time of the incident The date and time of the incident would be included in the incident report. Correct Name of the nurse who administered the medication The names of all parties present at the time of the incident would be included in the incident report. Correct Action taken in response to the incident The action taken in response to the incident or to remedy the situation would be included in the incident report.
On the nursing unit, you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? Information technology Electronic health record Personal health information Administrative information system
Electronic health record This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any healthcare delivery setting. In this system, you are able to access information about the patient during the current hospitalization and from four previous times when the patient accessed care. Information technology and personal health information are not a type of record system. The administration information systems support the effective use of information technology.
What is the main goal of the "Ticket-to-Ride" Communication Tool? Identify the intended destination of the patient Ensure appropriate patient care during transport and at the destination Document patient incidents during intrahospital transport Facilitate billing for transport-related staff time and patient care
Ensure appropriate patient care during transport and at the destination
How does computerized provider order entry (CPOE) contribute to patient safety? Select all that apply. Ensures legible orders Enables immediate billing Reduces the potential for delays in care Ensures medication prescribed is appropriate for the patient's condition Reduces the risk of transcription errors
Ensures legible orders Reduces the potential for delays in care Reduces the risk of transcription errors
A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "The patient is difficult to care for and refuses suggestions for improving appetite." Which directions does the manager give to the staff nurse who entered the note? Avoid rushing when charting an entry. Use correction fluid to remove the entry. Draw a single line through the statement and initial it. Enter only objective and factual information about the patient.
Enter only objective and factual information about the patient. Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record.
Which are expected documentation in nursing care? Select all that apply. Evaluation of nursing interventions Nursing assessment data Judgments about the patient's emotional and spiritual health Nursing care plan for the patient Nursing interventions conducted with the patient Nurse's opinions of the patient's recovery
Evaluation of nursing interventions Nursing assessment data Nursing care plan for the patient Nursing interventions conducted with the patient
How does the use of standardized nursing terminologies contribute to advances in the field of nursing? Enables secure and private electronic digital image transfer between facilities Facilitates measurement of the impact of nursing interventions on patient outcomes Reduces costs associated with printing nursing documentation Documents and summarizes nursing overtime hours to advocate for better work conditions
Facilitates measurement of the impact of nursing interventions on patient outcomes
A hospital faces a malpractice lawsuit due to a medical record error made by the on-call nurse. What kind of charting errors can lead to malpractice lawsuits? Failing to record drug allergies Failing to record the number of siblings of the patient Failing to record discontinued medications Failing to record the history of cancer Failing to record the patient information with legible writing
Failing to record drug allergies Failing to record discontinued medications Failing to record the history of cancer Failing to record the patient information with legible writing
Which statements regarding HIPAA are true? Correct HIPAA outlines legal penalties for nurses who breach security of health care data. HIPAA laws include legal penalties for any health care staff who breach security of health care data. HIPAA stands for Health Information Privacy and Accountability Act. HIPAA stands for Health Insurance Portability and Accountability Act, not Health Information Privacy and Accountability Act. Correct Nurses are legally and professionally responsible for understanding HIPAA. When using information technology, nurses are legally and professionally responsible for understanding all related laws and regulations, policies, and procedures, as well as the ethical codes of their employers and the ethical codes of their professional organizations. Correct HIPAA sets standards for how confidentiality of health care information must be maintained. HIPPA includes standards for how security and confidentiality of health care information must be maintained. Health care providers such as health care providers, nurse practitioners, and surgeons are not subject to legal penalties under HIPAA. Any health care staff who breach security of health care data are subject to legal penalties under HIPAA.
HIPAA outlines legal penalties for nurses who breach security of health care data. HIPAA laws include legal penalties for any health care staff who breach security of health care data Nurses are legally and professionally responsible for understanding HIPAA. When using information technology, nurses are legally and professionally responsible for understanding all related laws and regulations, policies, and procedures, as well as the ethical codes of their employers and the ethical codes of their professional organizations. Correct HIPAA sets standards for how confidentiality of health care information must be maintained. HIPPA includes standards for how security and confidentiality of health care information must be maintained..
Which statements exemplify the core principles of incident reporting? Select all that apply. Incident reporting provides an opportunity to learn from mistakes. Incident reporting punishes the individual at fault. All individuals must be able to report an incident without reprimand. Incident reporting should result in positive changes related to patient care and safety. Incident reporting should be done at the end of the shift so that the response to the incident can be included.
Incident reporting provides an opportunity to learn from mistakes. All individuals must be able to report an incident without reprimand. Incident reporting should result in positive changes related to patient care and safety.
How do computerized decision support systems (DSSs) contribute to patient safety? Includes safe practice alerts Computerized decision support systems (DSSs), utilized alongside or embedded within electronic medical records, include safe practice alerts and reminders that improve quality of care. Correct Assists in determining correct diagnoses Some DSSs assist in determining a correct diagnosis and choosing an appropriate medication. Correct diagnoses and medications enhance patient safety. Notifies the nurse when a patient is in distress DSSs do not notify the nurse when a patient is in distress. Correct Assists in selecting an appropriate medication Some DSSs assist in determining a correct diagnosis and choosing an appropriate medication. Correct diagnoses and medications enhance patient safety. Alerts the nurse when equipment is malfunctioning DSSs do not usually have the capabilities to notify the nurse when equipment is malfunctioning.
Includes safe practice alerts Computerized decision support systems (DSSs), utilized alongside or embedded within electronic medical records, include safe practice alerts and reminders that improve quality of care. Correct Assists in determining correct diagnoses Some DSSs assist in determining a correct diagnosis and choosing an appropriate medication. Correct diagnoses and medications enhance patient safety. Assists in selecting an appropriate medication Some DSSs assist in determining a correct diagnosis and choosing an appropriate medication. Correct diagnoses and medications enhance patient safety.
How is proper documentation of a patient's health information useful to medical insurance companies? Choose the best answer. It helps in providing preventive care to the patients. It helps in determining the diagnosis-related group (DRG) of the patient. It helps in reducing the cost of the monthly premium paid by the patient. It helps in reducing the cost of healthcare services provided to the patient.
It helps in determining the diagnosis-related group (DRG) of the patient. In order to determine healthcare reimbursements that have to be provided for the patient, insurance companies have to first determine the diagnosis-related group (DRG) of the patient. This can be done by referring to the patient's documented reports. Thus, it is very important that the information pertaining to the patient's health is well documented. Insurance companies do not provide preventive care to patients; preventive care is given by the provider. The amount that has to be paid for a premium is fixed and is not related to the patient's interventions. Proper documentation is not helpful in reducing the cost of healthcare services provided to the patient.
Incident report examples
Medication Error: a patient is given the incorrect dose of an analgesic Patient Fall: a child falls out of a hospital bed Equipment Malfunction: the cable of a powered bed sparks and starts to smoke Staff Injury: a patient knocks over an IV pole, which strikes a nurse on the head
In which way should errors be properly corrected in handwritten nursing documentation? Patient's initials beside the error and a line through the error Complete black out of the error and the nurse's signature Nurse's initials beside the error and a line through the error Complete black out of the error and no signature
Nurse's initials beside the error and a line through the error
The nurse is caring for a patient who is diagnosed with renal failure due to diabetes. The nurse has to pass the patient care to another nurse during change of shift. Which information should the nurse include in the hand-off report? Nursing diagnosis of the patient Routine care procedures for the patient All biographical information of the patient Important information about family members Recent changes in objective measurements
Nursing diagnosis of the patient Important information about family members Recent changes in objective measurements The patient's nursing diagnosis is an important component of the hand-off report because it guides the nursing care provided to the patient. Information about family members should be included in the report. It makes it easy to call them if required. Documentation of recent changes in the patient's condition is important, because the patient's condition may change the course of care provided to the patient. Routine care procedures like checking the IV site every 2 hours for signs of infection or infiltration should not be included in the hand-off report. The biographical information of the patient need not be included, because it is already available in the written form.
Which situations require an incident report? Select all that apply. Patient's ventilator malfunctions, causing the patient to experience respiratory distress Patient in the emergency department goes into cardiac arrest Nurse slips on a wet floor and twists an ankle Older adult patient on life support dies Patient is administered the wrong dosage of an opioid pain medication due to an error on the patient's chart
Patient's ventilator malfunctions, causing the patient to experience respiratory distress Nurse slips on a wet floor and twists an ankle Patient is administered the wrong dosage of an opioid pain medication due to an error on the patient's chart
Which statements are examples of ethical or legal concerns related to health care information technology? Select all that apply. Prevention of computer fraud and misuse Assignment of an EHR password to an authorized user Ownership and integrity of health care data Preservation of patient privacy and confidentiality IT training sessions held for all nursing
Prevention of computer fraud and misuse Ownership and integrity of health care data Preservation of patient privacy and confidentiality
Important functions of medical record
Promotes continuity of care and ensures that patients receive appropriate health care services. Can be used to assess quality-of-care measures, determine the medical necessity of health care services, support reimbursement claims, and protect health care providers, patients, and others in legal matters. Serves as a clinical data archive. Is a source of information for biomedical research and provider education, the collection of statistical data for government and other agencies, the maintenance of compliance with external regulatory bodies, and the establishment of policies and regulations for standards of care.
How does the use of standardized nursing language contribute to better patient outcomes? Select all that apply. Provides consistency in documentation Facilitates timely documentation Improves communication Enables data collection Protects patient privacy
Provides consistency in documentation Improves communication Enables data collection
In which way(s) does the decision support component of the electronic medical record assist health care providers? Select all that apply. Provides recommendations for treatment Allows ordering of a PET scan Describes past treatments Assists in the diagnostic process Provides reminders of preventive health actions such as vaccinations
Provides recommendations for treatment Assists in the diagnostic process Provides reminders of preventive health actions such as vaccinations
What is the main purpose of completing an incident report? Record the details of the incident for legal purposes Ensure a patient's record contains all information regarding the incident Record details of an incident and begin the process of an investigation Ensure all staff members are aware of the incident
Record details of an incident and begin the process of an investigation
Which statement related to documentation done by unlicensed assistive personnel (UAP) is true? Documentation by UAP is not part of the medical record. UAP are not authorized to document patient activities of daily care. Registered nurses are responsible for reviewing documentation by UAP. A registered nurse may only do intake and output documentation.
Registered nurses are responsible for reviewing documentation by UAP.
Which are benefits of the use of informatics in medical record management? Select all that apply. Remote access by multiple providers Elimination of data security concerns Compilation of data in one location Searchability of aggregate data Reduction of staff IT training needs
Remote access by multiple providers Compilation of data in one location Searchability of aggregate data
Which statements about bedside reporting are true? Select all that apply. Research suggests that bedside reporting increases patient safety and strengthens teamwork. Patients often perceive bedside reporting as intrusive. Bedside reporting includes the patient and family. Bedside reporting formats are usually open and unstructured. Nurses from the prior and oncoming shift must be physically present to view the patient.
Research suggests that bedside reporting increases patient safety and strengthens teamwork. Bedside reporting includes the patient and family. Nurses from the prior and oncoming shift must be physically present to view the patient.
When updating a patient's chart, the nurse erroneously documents a wrong medication. Upon realizing the mistake, what does the nurse do? Apply correction fluid and document the correct medication. Strike with a single line, tag it as an error, put initials, and document the correct medication. Rewrite the entire document again. Scratch out the error and document the correct medication.
Strike with a single line, tag it as an error, put initials, and document the correct medication.
Security of patient health data is governed by facility policy and HIPAA guidelines when accessed through which IT devices or systems? Select all that apply. Tablets and hand-held devices Bedside computers Paper charts Telehealth systems Electronic health record
Tablets and hand-held devices Bedside computers Telehealth systems Electronic health record
The nurse caring for a patient in a home care setting needs detailed documentation. What are the purposes of the documentation? The documentation justifies reimbursement. The documentation provides information regarding quality of work. The documentation provides data for acuity records. The documentation serves as a reference document for other professionals involved in the care. The documentation provides the health care team with detailed knowledge for coordination of
The documentation justifies reimbursement. The documentation provides information regarding quality of work. The documentation serves as a reference document for other professionals involved in the care. The documentation provides the health care team with detailed knowledge for coordination of In a home care setting, proper documentation is required for the justification of reimbursement of the care provided. It is also needed to provide information for the quality of work. A detailed document is required for an interprofessional plan of care and to provide the health care team with the detailed knowledge to facilitate the coordination of care. Acuity records are used to assess the hours of care and the duration of time the staff needed to take care of a patient.
EMR VS EHR
The electronic medical record (EMR) is a record of one care episode, such as an inpatient stay or an outpatient appointment. The electronic health record (EHR) is a longitudinal record of health that includes the inpatient and outpatient health care episodes from one or more care settings.
Which procedures must be followed when taking a verbal or telephone order? Select all that apply. The order must include the date and time received. The order must be repeated verbatim to the provider. All verbal and telephone orders must be taken by a health unit coordinator. The order does not need to include the nurse's signature. The order must be documented as a verbal or telephone order.
The order must include the date and time received. The order must be repeated verbatim to the provider. The order must be documented as a verbal or telephone order.
What are potential consequences of ineffectual or inaccurate hand-offs? Select all that apply. Patient health care outcomes may be improved. The patient may not get needed care. The patient's length of stay may be shortened. The risk of medication error may be increased. Errors in patient care may lead to patient injury or death.
The patient may not get needed care. The risk of medication error may be increased. Errors in patient care may lead to patient injury or death
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 option is the most appropriate documentation of the patient's emotional status? The patient has a defiant attitude and is demanding his test results. The patient appears to be upset with his nurse because he wants his test results immediately. The patient is demanding and complains frequently about his doctor. The patient stated that he felt frustrated by the lack of information he received regarding his tests.
The patient stated that he felt frustrated by the lack of information he received regarding his tests. "The patient stated that he felt frustrated by the lack of information he received regarding his tests" is a nonjudgmental statement regarding the nurse's observations about the patient. Statements about the patient being defiant or demanding are judgmental, and information in the medical record should be factual and nonjudgmental. The statement about the patient appearing to be upset needs to be more specific regarding the reason for the patient's concern.
A patient sustains an injury from a fall while on a hospital unit. The nurse makes an incident report. What is the purpose of the incident report? This report helps in identifying loopholes in the operation of the healthcare system. This report helps in providing good, quality healthcare. This report helps with regard to a patient's negative feedback related to the healthcare delivered. This report helps to determine the severity of the punishment to be delivered. This report helps to identify the need to change a procedure or policy.
This report helps in identifying loopholes in the operation of the healthcare system. This report helps in providing good, quality healthcare. This report helps to identify the need to change a procedure or policy. The report is a description of an incident such as a fall causing injury. Analysis of the incident or an occurrence report helps to identify the trends of the system or unit operation of the healthcare system. This helps in patient safety and quality improvement. It helps to identify the need to change procedures, services, or the infrastructure of a healthcare facility. It is an important part of the quality improvement program. The negative feedback of the patient regarding healthcare delivery is not recorded in the incident report. The incident report is not used to determine the severity of punishment to be applied to the person who is responsible for that incident.
How should an incident report be used to provide constructive analysis? To punish the responsible party Punishment of the responsible party is not a way an incident report can be used to provide constructive analysis. To document the incident for the patient's record Documentation of the incident for the patient's record is not a way an incident report can be used to provide constructive analysis. Correct To provide a framework for implementing change An incident report can allow for constructive analysis by providing a framework for implementing change. Correct To provide information to guide solutions An incident report can allow for constructive analysis by informing the development of solutions. Correct To disseminate information regarding the incident An incident report can allow for constructive analysis by disseminating information regarding the incident.
To provide a framework for implementing change An incident report can allow for constructive analysis by providing a framework for implementing change. Correct To provide information to guide solutions An incident report can allow for constructive analysis by informing the development of solutions. Correct To disseminate information regarding the incident An incident report can allow for constructive analysis by disseminating information regarding the incident.
Which statement describes the main purpose of the Nursing Minimum Data Set (NMDS)? To compile all the data a nurse obtains from patients into one file To minimize the amount of data collected in nursing practice To allow for remote health consultations To standardize the collection of essential nursing data
To standardize the collection of essential nursing data
A patient was shifted from the intensive care unit to the cardiac unit. What kinds of reports are used to communicate between the two units? Referrals Change-of-shift reports Transfer reports Discharge summary
Transfer reports Transfer reports are the types of hand-off reports used when patients are transferred from one unit to another. Referrals are made when the patient requires the services provided by another caregiver for a different category of health needs. Change-of-shift reports are handed over during the shift changes between nursing staff. A discharge summary is a report format used upon discharge of the patient. It contains the patient's discharge diagnosis, prognosis, and treatment plan.
Protected health information may be used for which purposes? Select all that apply. Treatment Payment Creating a case study Health care operations Solicitation
Treatment Payment Health care operations
A critical pathway in an orthopedic unit indicates that a patient should be afebrile, normotensive, and eupneic after knee replacement surgery. The nurse performs a postoperative examination of a patient's status after left knee replacement surgery and finds that the patient is experiencing a low-grade temperature. What is this finding called? Variance Positive variance Negative variance Critical finding
Variance Any unexpected outcome of a procedure, unmet goals, or an intervention not indicated in the critical pathway is called a variance. A positive variance is a positive, unexpected outcome, such as when a patient starts walking a day earlier than expected after surgery. There is no negative variance term that is used in documentation. A low-grade temperature is not a life-threatening sign in this patient, and thus cannot be considered as a critical finding.
Communication among the members of a healthcare team is essential to providing quality care to patients. Which are the modes for exchanging information among the members of the healthcare team? Pictures A thesis Written reports Oral communication Electronic cards
Written reports Oral communication The exchange of information amongst the healthcare team members is done through written reports and oral communication. Pictures of patients are not used in routine communication, but they may be used by specialists like dermatologists and plastic surgeons. The patient's health information is not exchanged through a thesis or electronic cards.
Informatics
is a broad academic field encompassing artificial intelligence, cognitive science, computer science, information science, and social science.
Nursing informatics
is a specialty area of informatics that addresses the use of health information systems to support nursing practice. The American Nurses Association (ANA, 2008) states that the specialty of nursing informatics integrates nursing computer and information science for the management and communication of data, information, knowledge, and wisdom.
Medical informatics
refers to informatics related to health care and describes a distinct specialty in the discipline of medicine. It deals with the resources, devices, and methods required for the acquisition, storage, retrieval, and use of information in health and biomedicine. In addition to computers, informatics tools in health care include clinical guidelines, formal medical terminologies, and information and communication systems.
SBAR
situation, background, assessment, recommendation often used in nursing as a hand-off tool and as a structured method for all communications between providers.