Documentation

Which standardized assessment tools are used for receiving health care funding from the Centers for Medicare and Medicaid Services?

-Resident Assessment Instrument -Minimum Data Set

What are benefits of the EHR?

-integrates all pertinent patient info -performs checks to support regulatory requirements -allows us to compare ongoing clinical data with baseline information

Failure to document these things commonly result in malpractice.

-pertinent health or drug info -nursing actions -medication administration -drug reactions or changes in condition

What are some drawbacks of narrative charting?

-repetition -length -disorganization

The data sets that are federally mandated for use in LTCs by CMS are?

-resident assessment instrument (RAI) -minimum data sets (MDS) -care area assessment (CAA)

____-____ ____ are classifications based on a patient's primary and secondary medical diagnoses that are used as the basis for establishing Medicare reimbursement for patient care.

Diagnosis-related groups

____ is a nursing action that produces a written account of pertinent patient data, clinical decisions and interventions, and patient responses in a health record.

Documentation

(T/F) Acuity ratings have no impact on staffing ratios.

False acuity ratings are used to determine the number and qualification of staff members

____ determines the reimbursement level under the prospective system for Medicare Part A residents.

MDS

____ documentation uses a story-life format.

Narrative

(T/F) Personal Health Information is the responsibility of all people working in healthcare.

True

Which are organizations that address the quality of health care documentation? a. American Nurses Association (ANA) b. The Joint Commission c. Diagnosis-related groups d. National Committee of Quality Assurance e. Health Insurance Portability and Accountability Act (HIPAA)

a. American Nurses Association (ANA) b. The Joint Commission d. National Committee of Quality Assurance

The nurse is preparing a patient for discharge. What should the nurse include in the discharge summary forms? Select all that apply. a. dietary restrictions b. follow-up care c. emergency contact numbers d. preoperative instructions e. acuity records

a. dietary restrictions b. follow-up care c. emergency contact numbers

The nurse is learning about SOAP charting. In what ways is SOAP different than PIE charting? Select all that apply. a. soap charting originated from medical records b. soap charting is based on the patient's problems c. soap charting includes assessment information d. soap charting has notes numbered based on patient's problems identified e. soap is structured into various sections

a. soap charting originated from medical records c. soap charting includes assessment information

Documentation must be _____ and ____.

accurate comprehensive

Why does documentation allow for better patient-centered care?

allows providers to know patient thoroughly and make patient-centered clinical decisions

____ _____ _____ is done when a patient meets all standards unless otherwise documented.

charting by exception

Data entered into the medical record provide a legal record of care provided. This justifies financial ____ from patients' _____.

compensation insurance

Effective documentation helps ensure ______ of care, saves _____, and minimizes risk of ______.

continuity time errors

A ____ is a combination of hardware and software that protects private network resources. It protects health info from hackers, network damage, theft, or misuse.

firewall

A ____ ____ is utilized when repeated observations are to be recorded in a quick and accurate manner.

flow sheet

Medical records serve as sources of research data. Why is this important?

important learning resource for nursing and healthcare education

____ or ____ records are common mistakes that may result in malpractice.

incomplete illegible

Accurate documentation is one of the best defenses for _____ _____ associated with nursing care.

legal claims

The intent of SOAP, SOAPIE, PIE, and DAR charting formats is to organize entries in the progress notes according to the _____ _____.

nursing process

What is a critical pathway?

outlines the actions that all members of a health care team must complete in a timely manner to achieve desired client outcomes and appropriate length of stay

The Health Insurance Portability and Accountability Act (HIPAA) was the first federal legislation to do what?

provide protection for patient medical records and information

The information communicated by nurses regarding their patients' care reflects the _____ of care and ____ for care provided.

quality accountability

Hospitals establish ____ ____ programs for conducting objective, ongoing reviews of patient care and to keep nurses informed of standards of nursing practice.

quality improvement

What is the main advantage of using computerized provider order entry (CPOE)?

reduces transcription errors

Why do researchers use patient records after securing agency and institutional review board approval?

to gather statistical data on incidence of problems and complications and come up with better EBP

Any unexpected outcome, unmet goal, or intervention not indicated in the critical pathway is called a ____.

variance

What does WDL mean?

within defined limits