Adult Health Chapter 26 Documentation

Which organization addresses the quality of health care documentation? select all that apply

-The joint commission -national committee for quality assurance (NCQA)

Which is the mode for exchanging information among members of the health care team? select all that apply

-written reports -oral communication

The nurse, after administering antibiotics, is updating a patient's chart in the emergency room. What elements of the report does the nurse accurately document in order to limit nursing liability in case of a legal claim? Select all that apply.

-current medications given -discontinued medications -drug allergies

which outcome is expected after effective documentation? select all that apply

-facilitation of proper insurance reimbursement -efficient use of time -enhanced continuity of care -protection for the nurse from legal recourse

Which statement describes the purpose of the incident report? select all that apply

-identifies loopholes in the operation of the health care system -provides, good quality health care -identifies the need to change a procedure or policy

Which guidance would the nurse provide when teaching students about legal guidelines for documentation? select all that apply

-record all facts -correct all errors promptly -chart only for yourself

Which precaution would the nurse take when documenting? Select all that apply

-record all facts -record all written entries legibly and in black ink -begin each entry with date and time and end with signature and title

A health care provider calls the nursing unit and requests the nurse on duty to update a patient's chart when the physician prescriptions are provided. Which action would the nurse perform? select all that apply

-record the date and time of the entry -record the source of the information and the mode of communication

Which standardized assessment tool is used for receiving health care funding from the centers for medicare and medicaid services? select all that apply

-resident assessment instrument (RAI) -minimum data set (MDS)

Which characteristic is an advantage of effective documentation? select all that apply

-saving time -minimizing error -effective continuity of patient care

The nurse is preparing a discharge summary for the patient with diabetes being discharged home on insulin. Which information would the nurse provide in the discharge summary? select all that apply.

-the contact information of the health care provider -the step-by-step instructions for self-administration of insulin -the signs and symptoms that have to be reported to the health care provider

A senior nurse is reviewing a nurse's documentation of a patient with pneumonia, "Blood pressure is 150/90 mmHg; pulse is 92 beats per minute, and the respiratory rate is 22 breaths per minute. The patient seems to have difficulty breathing. Sounds are produced when the patient exhales. Auscultation reveals rhonchi in the lower lung bases. Copious amounts of phlegm have been produced since morning." Which statement in the documentation is considered to be poor quality documentation and informatics? select all that apply

-the patient seems to have difficulty breathing -sounds are produced when exhaling -copious amounts of sputum produced since morning

Which information would the nurse include in a hand-off report at the end of shift? select all that apply

-the patients name, age and admitting diagnosis -allergies to food and medications -that the patients pain rating went from an 8 to a 2 on a scale of 1 to 10 after receiving 650mg of acetaminophen

At the end of a shift, the nurse documents a patient's condition, anticipated condition, medications, and nursing interventions fulfilled so that the next nurse can follow the appropriate treatment plan and care for the patient. This describes which type of report?

Hand-off report

Which law is the nurse violating when faxing a patients medical record to an unknown number?

The health insurance portability and accountability act of 1996 (HIPPA)

The nurse assesses a patient on day 3 after surgery and charts a progress note in the SOAP (subjective, objective, assessment, plan) format. Which datum is objective?

The patients incision site looks clean without purulent drainage or erythema

the nurse interprets the subjective and objective data and diagnoses a problem in a patient. Which step of the nursing process reflects this interpretation, according to SOAPIE (subjective, objective, assessment, plan, intervention and evaluation) format?

assessment

Which description is accurate for a system warning alerting the nurse an intervention is appropriate for a patient because of risk?

clinical decision support system

Which system in the electronic health record (EHR) provides warnings to alert a health care provider of patient allergies when prescribing medications?

clinical decision support system (CDSS)

How is proper documentation of a patients health information most useful to medical insurance companies?

determines the diagnosis-related group (DRG) of the patient

The ability to review patient education provided by other nurses is commonly in which type of record system?

electronic health record (EHR)

Which place is appropriate to document urine output in the patients chart?

flow sheet

Which response by the nurse is accurate for a patient requesting a copy of his or her medical record?

indicate that he or she has the right to read the record

A health care organization has incorporated information and computer technology. Which system will help the organization comply with the requirements of accrediting agencies?

nursing clinical information system

Which section of the traditional source record does the nurse use to record patient demographic information?

patient care summary

Where does the nurse access the information to contact the guardian of a patient?

patient care summary: contains patients demographic data such as name, DOB, address, contacts, age insurance, employment, guardians

Which method is appropriate for the nurse to dispose of printed patient information

place in a secure canister marked for shredding

In which section would the nurse place subjective and objective data?

progress notes

The health care provider prescribes a clear liquid diet for a patient with gastritis. On the first day, the patient consumes soup and tolerates it well. How does the nurse document this finding?

the patient had 2 cups of soup, which was tolerated well

Which statement indicates that the nurses understand the major advantage of using computerized provider order entry (CPOE)?

transcription errors are reduced when using CPOE