Documentation, Electronic Health Records, and Reporting

Document facts and subjective data from the patient.

9. The nurse recognizes which statement to be accurate regarding what should be documented? A. Document facts and subjective data from the patient. B. Document how he/she feels about the care being provided. C. Document in a "block" fashion once per shift. D. Double document as often as possible in order to not miss anything.

flow sheets

Data collected can be converted to a graph, which pictorially reflects patient data.

The order must be repeated verbatim to confirm accuracy.

If a verbal or phone order is necessary in an emergency, the nurse knows what action needs to be completed? a. The order must be taken by an RN or LPN. b. The order must be repeated verbatim to confirm accuracy. c. The order is documented as a written order. d. The order does not need further verification by the provider.

situation (what is happening the current time),

In SBAR the S stands for ?

assessment (what the nurse thinks the problem is),

In SBAR what does A stand for?

background (circumstances leading up to this situation),

In SBAR what does B stand for?

recommendation (what needs to be done to correct the situation).

In SBAR what does R stand for?

note is used to document problem (P), intervention (I), and evaluation (E).

PIE note

MAR

Prior to preparing to administer medications to the patient, the nurse should compare the provider orders with what document? a. Flow sheet b. Kardex c. MAR d. Admission summary

- to provide treatment for the patient - to determine billing and payment issues -to enhance health care operations related to the patient

The nurse knows that the Health Insurance Portability and Accountability Act (HIPAA) allows health information to be shared in which circumstances? (Select all that apply.) a. To provide treatment for the patient b. To determine billing and payment issues c. To enhance health care operations related to the patient d. In public areas such as the cafeteria or elevator e. Over the telephone with any family member

QD qod

The Joint Commission has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. The nurse identifies which abbreviations to be unacceptable? (Select all that apply.) a. prn b. QD c. qod d. 0.X mg e. X mg

Nursing assessment The care plan Interventions Patient responses to care

The nurse identifies which components to be expected nursing documentation? (Select all that apply.) a. Nursing assessment b. The care plan c. Critique of the physician's care d. Interventions e. Patient responses to care

Handoff can lead to patient death if done incorrectly.

The nurse identifies which statement to be accurate regarding the process of making a change-of-shift report (handoff)? a. Handoff is an uncommon occurrence of little importance. b. Handoff occurs only at change of shift and only to oncoming nurses. c. Handoff can lead to patient death if done incorrectly. d. Handoff does not allow for collaboration or problem solving.

High-quality nursing documentation reflects the nursing process.

The nurse identifies which statement to be true regarding nursing documentation? A. Standards for documentation are established by a national commission. B. Medical records should be accessible to everyone. C. Documentation should not include the patient's diagnosis. D. High-quality nursing documentation reflects the nursing process.

It can be used as a tool for biomedical research and provide education.

The nurse identifies which true statement regarding the medical record? A. It serves as a major communication tool but is not a legal document. B. It cannot be used to assess quality of care issues. C. It is not used to determine reimbursement claims. D. It can be used as a tool for biomedical research and provide education.

Electronic health record (EHR)

The nurse is admitting a patient who has had several previous admissions. To obtain a knowledge base about the patient's medical history, the nurse would access which document? A. Electronic medical record (EMR) B. The computerized provider order entry (CPOE) C. Electronic health record (EHR) D. Primary provider's office notes

Admission summary

The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. What is the best central location for the nurse to obtain this information? a. Admission summary b. Discharge summary c. Flow sheet d. Kardex

The nurse should never share any password with anyone.

The nurse is caring for patients on a unit that uses electronic health records (EHRs). What action by the nurse protects personal health information? A. The nurse should allow only nurses that he/she knows and trusts to use his/her verification code. B. The nurse should not worry about mistakes since the information cannot be tracked. C. The nurse should never share any password with anyone. D. The nurse should be aware that the EHR is sophisticated and immune to failure.

Paper is fragile and susceptible to damage.

The nurse knows that paper records are being replaced by other forms of record keeping for what reason? A. Paper is fragile and susceptible to damage. B. Paper records are always available to multiple people at a time. C. Paper records can be stored without difficulty and are easily retrievable. D. Paper records are permanent and last indefinitely.

The nursing process

The nurse recognizes that nursing documentation is guided by what process? A. The nursing process B. NANDA-I, nursing diagnoses C. Nursing interventions classification D. Nursing Outcomes Classification

Accurate documentation is needed for proper reimbursement.

The nurse understands the need for accurate documentation due to which fact? A. Accurate documentation is needed for proper reimbursement. B. Accurate documentation must be electronically generated. C. Accurate documentation does not include e-mails or faxes. D. Accurate documentation is only accepted in court if written by hand.

Standardized language provides consistency. Standardized language improves communication among nurses. Standardized language increases the visibility of nursing interventions. Standardized language enhances data collection. Standardized language supports adherence to care standards.

The nurse understands the use of standardized language in care planning is beneficial for what reasons? (Select all that apply.) a. Standardized language provides consistency. b. Standardized language improves communication among nurses. c. Standardized language increases the visibility of nursing interventions. d. Standardized language enhances data collection. Standardized language supports adherence to care standards.

They improve patient health status.

The nurse understands which statement about the use of electronic health records is true? A. They improve patient health status. B. They require a keyboard to enter data. C. They have not reduced medication errors. D. They require increased storage space.

- Patient's blood pressure has dropped from 142/92 to 98/48 mmHg: S - Patient is hemorrhaging with four saturated dressings in an hour: A - The patient took an overdose of antidepressants three days ago: B - By policy, the patient needs transferred to the ICU; please come write the orders: R

The nursing student is learning about SBAR reporting. What statements about the patient are matched with the correct part of the report? (Select all that apply.) a. Patient is an 84-year-old female with a history of hypertension: S b. Patient's blood pressure has dropped from 142/92 to 98/48 mmHg: S c. Patient is hemorrhaging with four saturated dressings in an hour: A d. The patient took an overdose of antidepressants three days ago: B e. By policy, the patient needs transferred to the ICU; please come write the orders: R

Draw a single line through the error write "error" above or after the entry, along with the nurse's initials.

What action should the nurse take to correct an error in paper charting? a. Remove the sheet with the error and replace it with a new sheet with the correct entry. b. Scribble out the error and rewrite the entry correctly. c. Draw a single line through the error write "error" above or after the entry, along with the nurse's initials. d. Leave the entry as is and tell the charge nurse.

S: situation B: background A: assessment R: recommendation

What does SBAR stand for?

They are examples of problem-oriented charting.

What fact does the nurse know applies to PIE, APIE, SOAP, and SOAPIE documentation? A. They are chronologic. B. They are examples of problem-oriented charting. C. They are narrative charting. D. They are forms of "charting by exception."

Log-on access to the electronic record identifies the person charting.

What fact is the nurse aware of when charting using electronic documentation? a. Errors can be corrected and totally removed from the record in the screen view. b. Log-on access to the electronic record identifies the person charting. c. Each entry requires the nurse to sign her/his name and credentials. d. Documenting significant changes in the electronic record ends the nurse's responsibility.

The medical record, in any format, is the most reliable source of information in a legal action.

What fact is the nurse aware of when charting using paper nursing notes? a. Use red ink so the nursing entries stand out. b. When mistakes are made in documentation, the nurse should white out the entry. c. Only one nurse should document on a sheet so that it can be removed in case of error. d. The medical record, in any format, is the most reliable source of information in a legal action.

-the patient problems -any actions initiated -the patient's response to interventions

When charting is done using the DAR charting format, the nurse documents which components? (Select all that apply.) a. The patient problems b. Subjective data c. Any actions initiated d. Objective data e. The patient's response to interventions

Use black ink unless the facility allows a different color.

When the nurse is charting in the paper medical record, what action does the nurse carry out? A. Print his/her name since signatures are often not readable. B. Omit nursing credentials since only the nurses chart C. Skip a line between entries so that it looks neat. D. Use black ink unless the facility allows a different color.

Complete an incident report as a risk management document.

When the patient has had a fall while trying to climb out of bed, the nurse must carry out which task? a. Complete an incident report as a risk management document. b. Complete an incident report and add it to the medical record. c. Document that an incident report was completed in the medical record. d. Say nothing about the incident in the medical record.

Narrative

charting is chronologic, with a baseline recorded on a shift-by-shift basis

Narrative

charting may stand alone, or it may be complemented by other tools.

Flow sheets and checklists

may be used to document routine care and observations that are recorded on a regular basis, such as vital signs, and intake and output measurements.

A medication administration record (MAR)

is a list of ordered medications, along with dosages and times of administration, on which the nurse initials medications given or not given

charting by exception (CBE)

is documentation that records only abnormal or significant data.

SOAP note

is used to chart the subjective data (S), objective data (O), assessment (A), and plan (P).

Kardex

was a nonpermanent filing system for nursing records, orders, and patient information that was held centrally on the unit.