Sherpath- EHR

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 -Determining health care needs -Providing external provider support -Using CPOE to manage prescriptions a. System connectivity b. Remote access c. Point-of-care information d. System integration

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

Match the type of documentation error to its probable result. -Inappropriate order of care -Missing medication dose -Misinterpretation -Patient care not validated a. Lack of clarity b. Erroneous abbreviation c. Omission d. Late entry

Inappropriate order of care: d. Late entry Missing medication dose: c. Omission Misinterpretation: b. Erroneous abbreviation Patient care not validated: a. Lack of clarity

Match the documentation type to its description. -Includes rows and columns for assessments and outcomes -Is the most used problem-oriented method -Requires evaluation of nursing intervention -Incorporates established best practices for patient outcomes a. PIE b. Flowsheet c. SOAP d. Clinical pathway

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

Match the electronic health record benefit with the example. -Nurse getting patient data from mobile device -Patient checks his/her blood sugar result -Electronic care instructions -Connectivity to all hospital systems a. Electronic health record (EHR) system interface b. Convenient access to patient records c. Self-participation in care d. Power outage reduction e. Discharge planning

Nurse getting patient data from mobile device: b. Convenient access to patient records Patient checks his/her blood sugar result: c. Self-participation in care Electronic care instructions: e. Discharge planning Connectivity to all hospital systems: a. Electronic health record (EHR) system interface

The new nurse is learning to use the electronic health record (EHR). Which knowledge and skills must nurses have to effectively use the EHR? Select all that apply. a. Computer literacy b. Password protection and security c. Communication management d. Database programming e. Timed use of the system

a. Computer literacy b. Password protection and security c. Communication management

Which characteristic distinguishes the Charting by Exception documentation format? a. Documentation of clinically significant findings b. Inclusion of all past data, but no present data c. Documentation of all care d. Documentation of only expected findings

a. Documentation of clinically significant findings

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? Select all that apply. a. Documenting patient data in front of other colleagues b. Using white correction fluid to correct an error on a paper chart c. Completing documentation at the end of shift d. Including the date and time of any documentation corrections e. Including the date, time, and electronic signature on all electronic health record entries

a. Documenting patient data in front of other colleagues b. Using white correction fluid to correct an error on a paper chart c. Completing documentation at the end of shift

Decision-making in health care is facilitated using clinical decision support systems (CDSSs). Which descriptions pertain to specific CDSSs? Select all that apply. a. Eases the ability to schedule patient care needs b. Provides health care information on patient allergies c. Allows nurses to develop patient care plans d. Provides electronic medication administration record (eMAR) information to caregivers e. Allows nurses to document patient needs in rows and columns

a. Eases the ability to schedule patient care needs b. Provides health care information on patient allergies c. Allows nurses to develop patient care plans

The nurse is documenting patient care using a non-problem-oriented team approach. Which type of documentation is the nurse using? a. Flowsheet documentation b. PIE documentation c. SOAP documentation d. Source documentation

a. Flowsheet documentation

Which key element must nurses understand about the electronic health record (EHR)? a. It was developed to create a safe, secure environment for patient data. b. It was developed to complement a paper chart. c. It was developed to help meet government regulations. d. It was developed to be a data storage system.

a. It was developed to create a safe, secure environment for patient data.

The nurse is caring for a patient with hypertension, frequently taking the patient's blood pressure, and documenting it in the electronic health record. Blood pressure is an example of which type of data? a. Objective data b. Subjective data c. Care-planning data d. Outcome data

a. Objective data

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? Select all that apply. a. Provides documentation consistency b. Facilitates timely documentation c. Facilitates communication d. Enables data trending across units e. Protects patient privacy

a. Provides documentation consistency c. Facilitates communication d. Enables data trending across units

The nurse is caring for a patient admitted to the unit with a cough and fever. Which example illustrates enhanced decision support as a benefit of the electronic health record? a. Taking action based on rapid blood sugar test results b. Accessing patient data from a mobile device c. Accessing a chest x-ray and laboratory results for a patient with breathing difficulty d. Providing electronic copies of discharge prescriptions

a. Taking action based on rapid blood sugar test results

The nurse is caring for an older adult patient with diabetes. Which statements identify the use of key documentation standards developed by the American Nurses Association (ANA)? Select all that apply. a. The nurse documents the patient's diabetes medication administration in the electronic Medication Administration Record (eMAR). b. The nurse logs out of the computer after entering patient information and data. c. The nurse documents the patient's blood sugar per prescriptions 2 hours after breakfast. d. The nurse documents his or her thoughts about what medications the patient should be taking because the patient's blood sugar is elevated. e. The nurse documents the patient assessment in his or her own words to better describe the patient's needs.

a. The nurse documents the patient's diabetes medication administration in the electronic Medication Administration Record (eMAR). b. The nurse logs out of the computer after entering patient information and data. c. The nurse documents the patient's blood sugar per prescriptions 2 hours after breakfast.

Which standard electronic health record (EHR) component is required for patient care? a. Bar-coding system b. Electronic medication system c. Flowsheet charting d. Workflow support system

b. Electronic medication system

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? a. Add the patient's initials beside the error, and draw a line through the error. b. Completely black out the error and the nurse's signature. c. Place the nurse's initials beside the error, and draw a line through the error. d. Completely black out the error, and do not add a signature.

c. Place the nurse's initials beside the error, and draw a line through the error.

Which are primary functions of the electronic health record? Select all that apply. a. Provides evidence of health care provider opinions b. Allows the use of shared passwords for ease of use c. Provides patient information for planning care d. Provides interdisciplinary documentation review e. Allows access to decision support tools for ease of care

c. Provides patient information for planning care d. Provides interdisciplinary documentation review e. Allows access to decision support tools for ease of care

The nurse is using SOAP notes to document care on a postoperative patient. Which elements comprise a SOAP note? a. Summary, objective, assessment, and problem b. Staff name, objective data, assessment, and problem c. Subjective data, objective data, assessment, and plan d. Summary, objective data, assessment, and plan

c. Subjective data, objective data, assessment, and plan