Ch 26: Documentation & Informatics

A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.)

- Communication - Legal documentation - Reimbursement - Research - Education

Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)

- Gives a change-of-shift report to the oncoming nurse about the patient - Reads the progress notes of assigned patient's record

A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)

- Implement an automatic sign-off. - Use a programmed speed-dial key when faxing. - Impose disciplinary actions for inappropriate access. - Shred papers containing personal health information (PHI).

A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete?

A verbal report

Which entry will require follow-up by the nurse manager? 0800 Patient states, "Fell out of bed." Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, "Did not pass out." Assisted back to bed. Call bell within reach. Bed monitor on. ——————-Jane More, RN 0810 Notified primary care provider of patient's status. New orders received. ——————-Jane More, RN 0815 Portable x-ray of L hip taken in room. States, "I feel fine." ——————-Jane More, RN 0830 Incident report completed and placed on chart. ——————-Jane More, RN

0830

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?

12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing?

A minimum data set

A nurse is providing care to a group of patients. Which situation will require the nurse to obtain a telephone order?

At 0100, a patient's blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood.

A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take?

Chart on the computer immediately after care is provided.

A nurse is charting on a patient's record. Which action will the nurse take that is accurate legally?

Charts legibly

A patient is being discharged home. Which information should the nurse include?

Community resources

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using?

Critical pathway design

A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting?

Demonstrated use of crutches

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking?

Determining the degree to which standards of care are met by reviewing patients' health records

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?

Document the variance in the patient's record.

A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse find?

Electronic health record

A nurse wants to find the daily weights of a patient. Which form will the nurse use?

Graphic record and flow sheet

A nurse is completing an OASIS data set on a patient. The nurse works in which area?

Home health

A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session?

Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care.

A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up?

If a nurse has computer competency, the nurse is competent in informatics.

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?

Left knee incision 1 inch in length without redness, drainage, or edema

A nurse developed the following discharge summary sheet. Which critical information should the nurse add? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge

Mode of transportation

A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe?

Reduced errors of omission

A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record?

Reports to third-party payers

A nurse is preparing to document a patient who has chest pain. Which information is critical for the nurse to include?

Sharp pain of 8 on a scale of 1 to 10

After providing care, a nurse charts in the patient's record. Which entry will the nurse document?

Skin pale and cool

A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to follow up?

The new nurse charts consecutively on every other line.

A nurse is charting. Which information is critical for the nurse to document?

The patient received a pain medication, Lortab.

A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene?

The student nurse shares patient information with a friend.

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient?

Upon administration

A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement?

Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.