ATI 7: Documentation

A nurse is reviewing documentation principals with a group of newly hired assistive personnel (AP). Which of the following should the nurse include?

A nurse who delegates a task to an AP will review the charting for that task

A nurse is discussing computerized provider order entry systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE system?

CPOE systems can increase the speed of care delivery

A nurse is talking with a client about the electronic health record at the facility. Which of the following client statements indicates an understanding of EHRs?

I will be able to track my health information

A nurse in the clinic is reviewing a clients prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed?

PRN

A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include?

Personnel can be terminated for breaching a client's confidentiality

A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include?

A problem-oriented medical record uses progress notes, which promotes information sharing among members of the interdisciplinary team.

A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information?

"I can take a telephone prescription if a provider is directing a cide for an unresponsive client."

A nurse is reviewing the documentation of a newly licensed nurse. Which of the entries should the nurse identify as meeting the American Nurses Association (ANA) standards of documentation?

"The client vomited 240 mL of clear emesis but denies pain or nausea"

A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on the joint commissions do not use list?

MSO4, IU, qhs

A nurse manager is reviewing the documentation of for newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly?

Synthroid 100 mg PO every morning ac

A nurse is caring for a client after a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first?

The admitting provider, the charge nurse on the unit, the client

A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following should the nurse include as a benefit of electronic documentation?

The system alerts providers of possible actions that could cause client harm

A nurse is documenting information in a clients chart and makes the entry quotation mark client reports "abdominal pain on exertion". Which of the following documentation format describes this entry?

The S in soap

A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication?

By mouth

A newly licensed nurse is orienting to a facilities documentation process. The facility requires staff to on,y document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods?

Charting by exception

A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include?

Facilities can establish their own rules for documentation methods

A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record?

Immunization data

A charge nurse is reviewing soap documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data?

Rebound tenderness noted in RLQ of the abdomen

A charge nurse is reviewing characteristics of electronic documentation with staff at a providers office. Which of the following characteristics should the charge nurse plan to include?

Reduces medical errors, makes clients medical history more easily available, increases accuracy of coding procedures

A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs.

The Institute of Medicine (IoM)