Documentation ATI

A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include? -A problem-oriented medical record is created using the PIE model for documentation entries -A problem-oriented medical record contains separate sections for lab and diagnostic info -A problem-oriented medical record promotes info sharing among members of the interdisciplinary team -A problem-oriented medical record is rarely used in acute care settings

A problem-oriented medical record promotes info sharing among members of the interdisciplinary team

A newly licensed nurse is orienting to a facility's documentation system. The facility requires staff to only document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods? -Charting by exception -Subjective, objective, assessment, plan format -Problem, intervention, evaluation model -Data, action, response charting

Charting by exception

A nurse is caring for a client following a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first? (Select all that apply.) -The admitting provider -The charge nurse on the unit -The client's sibling -The client -The client's spiritual advisor

The admitting provider, The charge nurse on the unit, The client

A nurse is discussing computerized provider order entry (CPOE) systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE system? -"CPOE systems are associated with a slightly higher error rate." -"CPOE use does not include medication prescriptions." -"CPOE systems can increase the speed of care delivery." -"CPOE use is mandated by HIPAA under the Privacy Rule."

"CPOE systems can increase the speed of care delivery."

A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information? -I can take a telephone prescription if a provider is making routine rounds in another area -I can take a telephone prescription if a provider is directing a code for an unresponsive client. -If a client requires an over-the-counter medication for relief of nausea, it is okay to accept a telephone prescription -If a client requires pain control for a terminal condition, it is okay to accept a telephone prescription

"I can take a telephone prescription if a provider is directing a code for an unresponsive client."

A nurse is talking with a client about their electronic health record (EHR) at the facility. Which of the following client statements indicates an understanding of EHRs? -"I will be able to track my health info." -"My personal info will be entered into a national database." -"I will have one EHR that will encompass the health care i've received over my lifetime." -"The goal of EHRs is to improve insurance coding."

"I will be able to track my health information."

A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include? -"Accessing the medical record of clients on units other than where you are assigned is allowed." -"There are large financial penalties for charting vital signs you obtain for another nurse's client." -"Personnel can be terminated for breaching a client's confidentiality." -Once you have cared for a client, it is acceptable to look at their medical record on subsequent health care visits."

"Personnel can be terminated for breaching a client's confidentiality."

A nurse is reviewing documentation principles with a group of newly hired assistive personnel (AP). Which of the following information should the nurse include? -Providers designate to other staff which abbreviations cannot be used -A nurse who delegates a task to an AP will review the charting for that task -Providers read and cosign nursing documentation -Licensed personnel should document out-of-range vital signs for AP

A nurse who delegates a task to an AP will review the charting for that task

A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication? -By mouth -Intramuscularly -Per rectum -Intravenously

By mouth

A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include? -ANA standards prevent client records from being used for legal proceedings -HIPAA regulations vary from one state to another -Privacy regulations apply to electronic data transfer rather than verbal communication -Facilities can establish their own rules for documentation methods

Facilities can establish their own rules for documentation methods

A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs? -IOM -Department of Veteran Affairs -American Hospital Association -The Joint Commission

IOM

A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record? -Immunization data -Record of client health care payments -complete medical info for household members -Facility policies

Immunization records

A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on The Joint Commission's Do Not Use List? (Select all that apply.) -MSO4 -IU -PO -qhs -NKA

MSO4, IU, qhs

A nurse in a clinic is reviewing a client's prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed? -PRN -NPO -AC -Ad lib

PRN

A charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data? -The client states, "I've had abdominal pain for the past 3 days." -The client reports consuming about 1,500 mL of water per day -Rebound tenderness noted in RLQ of the abdomen -Recommend client referral to a registered dietitian

Rebound tenderness noted in RLQ of the abdomen

A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's office. Which of the following characteristics should the charge nurse plan to include? (Select all that apply.) -Reduces medical errors -Improves listening skills among interdisciplinary team members -Less convenient than paper-based charting -Makes client medical history more easily available -Increases accuracy of coding procedures

Reduces medical errors, Makes client medical history more easily available, Increases accuracy of coding procedures

A nurse manager is reviewing the documentation of four newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly? -Synthroid 100 mg PO every morning ac -Enoxaparin 75 mg SQ bid -Digoxin 0.25 mg PO qd -Metformin 500.0 mg PO with evening meal

Synthroid 100 mg PO every morning ac

A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on exertion." Which of the following documentation formats describes this entry? -The "I" in PIE -The "S" in SOAP -The "R" in DAR -The "E" in PIE

The "S" in SOAP

A nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries should the nurse identify as meeting the American Nurses Association (ANA) standards for documentation? -The client is now asleep, and they ate most of their breakfast a few hours ago -The client vomited 240 mL of clear emesis but denies pain or nausea -The client reports not feeling good, but they look fine -The client has 8 to 10 sores on their body

The client vomited 240 mL of clear emesis but denies pain or nausea

A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following information should the nurse include as a benefit of electronic documentation? -The system alerts providers of possible actions that could cause client harm -An electronic system prevents breaches of confidentiality of client data -Providers can document client info in the electronic record during system downtime -System encryption eliminates the need for security firewalls

The system alerts providers of possible actins that could cause client harm