PrepU - Documenting, Reporting, Conferring, and Using Informatics

graphic sheet

A _______ is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.

plan of care

A ________ should be generated at admission and revised to reflect changes in the client's condition.

a

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for patients diagnosed with multiple sclerosis, and their families. Providing this information is an example of which of the following? a) A referral b) Conferring c) A consultation d) Reporting

b

A concise document that provides most of the client's nursing and medical information is a(n) a) Past chart b) Kardex c) Office record d) Nursing care plan

a

A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of what? a) Nursing informatics b) Electronic medical records c) Telemedicine d) Computerized documentation

b

A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?1. a) The laboratory assistant does not have the correct password. b) The laboratory assistant can only retrieve medical records but cannot view the details. c) The laboratory assistant does not have the correct access number. d) The laboratory assistant is trying to view archived data.

c

A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as the first step? a) Nursing activities during a shift b) Data, action, and response c) Problem selected d) Plan of care

a

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? a) Intervention carried out b) Multidisciplinary interventions c) Written plan of care d) Client assessment

cbe

A significant drawback to _______ is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. It is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

c

In many institutions, which of the following telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner? a) Orders for respiratory treatments b) Orders for dietary changes c) Orders for antibiotics d) Orders for diagnostic studies

b

What activity in charting will assist most in the avoidance of errors? a) Organization b) Timeliness c) Legibility d) Objectivity

d

What dual purpose does an audit serve? a) Knowledge and quality b) Communication and evaluation c) Education and confidentiality d) Quality assurance and reimbursement

d

What organization audits charts regularly? a) National League for Nursing b) Sigma Theta Tau International c) American Nurses Association d) Joint Commission on Accreditation of Healthcare Organizations

narrative note

A _______ in a skilled nursing facility might include the type of morning care, nutritional intake, client activity pattern, and comfort measures provided, along with the client's response.

d

Charting in which the nurse writes a progress note that relates to one health problem is a a) Narrative note b) Flow sheet c) PIE note d) SOAP note

DAR

Focus _______ notes organizes entries by data, action, and response.

confidentiality

Documentation and reporting of the patient's condition require adherence to the highest standard of _______.

c

During a client's hospitalization, he has developed shortness of breath, with edema. What action should the nurse take? a) Involve the family in changes b) Review the nursing care plan c) Revise the plan of care d) Implement changes in the current interventions

A

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation? a) It provides quick access to abnormal findings. b) It provides and refers to client's problem by a number. c) It records progress under problems, intervention, and evaluation. d) It documents assessments on separate forms.

c, d, e

Select all answer choices that apply. Which of the following information about the patient would a nurse include as part of a minimum data set when using electronic medical records? Select all that apply. a) Health history b) Physical assessment c) Admission date d) Insurance e) Sex/gender

Kardex

The ______ is a way to ensure continuity of care from one shift to another and from one day to the next.

SOAP

The _______ method begins by selecting a problem from a list.

narrative notes

The _________ are used to record relevant client and nursing activities throughout a shift.

pie

The client's problems are given a corresponding number in the _______ charting method, which is used in the progress notes when referring to interventions and the client's responses. Assessments are documented on separate forms

d

The highest standard for maintaining a patient's condition is a) Documentation b) Management c) Reporting d) Confidentiality

minimum data set

The nursing _______ is organized into three categories: nursing care elements (such as nursing diagnoses and interventions), patient demographic elements (such as sex, date of birth, and ethnicity), and service elements (such as admission and discharge dates and expected payer for services). Does not include physical assessment and history.

a

When maintaining medical records for a client, the nurse knows that a medical record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting? a) Ensure that the client's name appears on all pages. b) Use abbreviations wherever possible. c) Leave spaces between entries and signature. d) Record all facts and subjective interpretations.

c

Which documentation tool will the nurse use to record the patient's vital signs every 4 hours? a) Acuity charting forms b) Medication record c) A graphic sheet d) 24-hour fluid balance record

acuity

_______ charting forms allow nurses to rank patients as high to low acuity in relation to the patient's condition and need for nursing assistance or intervention.

SBAR

_______ communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members. It is considered a framework for communication rather than a format for documentation.

EMAR

_______ documents medication administration.

SOAP

_______ is a progress note that relates to only one health problem.

nursing informatics

_______ is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. A specific application of this is the use of PDAs in the clinical setting. The devices are less likely to be used to perform documentation or to constitute client records. Telemedicine involves the remote provision of care.

SBAR

_______ is the communication tool to provide critical client information to the healthcare provider.

consultation

_______ is the process of inviting another professional to evaluate the client and make recommendations to you about his or her treatment.

referring

_______ is the process of sending or guiding the client to another source for assistance.

PIE

_______ notes incorporate the plan of care into the progress notes.

cbe

_______ provides quick access to abnormal findings as it does not describe normal and routine information.

reporting

________ is the oral, written, or computer-based communication of client data to others.

conferring

________ is to consult with someone to exchange ideas or seek information, advice, or instructions.

CBE

________ permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution.