Sherpath Documentation
Protected health information may be used for which purposes?
-Treatment. -Payment. -Health care operations.
How does the medical record function as a communication tool?
Allows staff to access patient information simultaneously.
What are the elements of a SOAP note?
Subjective data, objective data, assessment, and plan.
Which statement describes the difference between the function of an electronic health record (EHR) and an electronic medical record (EMR)?
The EHR is a record of MORE than one care episode, whereas the EMR is a record of ONE episode of care.
High-quality nursing documentation is characterized by which important elements?
-Accessibility of documentation. -Relevance of documentation. -Timeliness of documentation. -Thoughtfulness of documentation.
Which information should be recorded for every entry in the medical record?
-Date. -Time. -Nurse's signature.
Which statements describe problem-oriented medical records and documentation?
-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 are expected documentation in nursing care?
-Evaluation of nursing interventions. -Nursing assessment data. -Nursing care plan for the patient. -Nursing interventions conducted with the patient.
Which are primary functions of the medical record?
-Protects health care providers in legal matters. -Is a source of information for statistical data. -Provides a record of compliance with health care regulations.
How does the use of standardized nursing language contribute to better patient outcomes?
-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?
-Provides recommendations for treatment. -Assists in the diagnostic process. -Provides reminders of preventive health actions such as vaccinations.
Which procedures must be followed when taking 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.
In which section of the EMR would a nurse find laboratory test values?
Diagnostic results.
Which characteristic distinguishes the charting by exception documentation format?
Documentation of only unexpected or clinically significant findings.
In which way should errors be properly corrected in handwritten nursing documentation?
Nurse's initials beside the error and a line through the error.
Which statement related to documentation done by unlicensed assistive personnel (UAP) is true?
Registered nurses are responsible for reviewing documentation by UAP.
