Electronic Health Record

The nurse is caring for a patient admitted with opioid use disorder. Match the electronic health record benefit with the step used in patient care.

Assessing opioid blood level System connectivity Determining health care needs Point-of-care information Providing external provider support Remote access Using CPOE to manage prescriptions System integration

The new nurse is learning to use the electronic health record (EHR). Which knowledge and skills must nurses have to effectively use the EHR?

Computer literacyUse of the EHR requires basic computer literacy or understanding how a computer works. Lack of computer literacy could have safety, security, and accuracy implications. Password protection and securityData security is a major component of the EHR requiring individual passwords that are not to be shared. Understanding password protection and security strengthens the safety and security of patient information. Communication managementThe EHR allows for interdisciplinary communication ensuring that patient needs are met, care plans reflect current information, and cost-containment measures are effective, such as not repeating diagnostic tests already performed.

The nurse is documenting patient care using a non-problem-oriented team approach. Which type of documentation is the nurse using?

Flowsheet documentation Flowsheet documentation uses abbreviated forms of documentation generally recorded on a regular basis.

Match the documentation type to its description.

Includes rows and columns for assessments and outcomes Flowsheet Is the most used problem-oriented method SOAP Requires evaluation of nursing intervention PIE Incorporates established best practices for patient outcomes Clinical pathway

The nurse made an error in documenting a patient's care. Which method would the nurse use for correcting a documentation error in a paper chart?

Place the nurse's initials beside the error, and draw a line through the error. An error should be documented by placing a single line through the error, writing the correct information above or below the line, and including the nurse's signature.

Which standard electronic health record (EHR) component is required for patient care?

Electronic medication system All EHRs are required to have a system for electronically monitoring medication distribution to help reduce medication errors.

The nurse is caring for a patient transferred from the intensive care unit to the unit. In which ways would the use of standardized nursing language contribute to more favorable patient outcomes?

Provides documentation consistency The use of standardized nursing language provides documentation consistency across units and disciplines. Facilitates communication Using standardized nursing language improves communication among nurses and other health care providers. Enables data trending across units. Standardized nursing language enables data collection and allows trending of care across un

Which are primary functions of the electronic health record?

Provides patient information for planning careThe electronic health record enables the use of accurate, up-to-date patient-related information to help nurses plan care. Provides interdisciplinary documentation reviewThe electronic health record provides an interdisciplinary approach to patient care by allowing all health care providers to see patient information for better patient care decisions. Allows access to decision support tools for ease of careThe electronic health record allows access to all patient care areas, often as dashboards, for help in health care decision-making.

Nursing documentation is both a patient care and legal process. Which actions would indicate that the nurse requires further education on the legal implications of documentation?

Documenting patient data in front of other colleaguesPatient-related documentation should be done privately to protect the confidentiality of patient information. Using white correction fluid to correct an error on a paper chartDocumentation should never be obliterated. Error correction in a paper chart should follow accepted measures such as drawing a single line through the error, noting the correct response, and initialing and dating the entry. Completing documentation at the end of shiftLeaving documentation until shift end places a risk of not adequately remembering essential patient-related data and may encourage rapid and possible minimal data entry as a result of time constraints (e.g., need to end shift).