Chapter 26 - Informatics and Documentation (exam 5)

nursing evaluation

E in PIE documentation

electronic medical record

patient's record within an integrated health care information system for an individual visit to a health care provider's office or for an individual admission to an acute care setting that allows for seamless documentation of the progression of care

charting by exception

philosophy that all standards for normal assessment findings or for routine care activities are met unless otherwise documented

response of the patient

R in DAR documentation

subjective

S in SOAP documentation

clinical information system

"patient care information system", large, computerized database management system that is used to access patient data needed to plan, implement, and evaluate care

action or nursing intervention

A in DAR documentation

assessment

A in SOAP documentation

b (the client is exercising their right to make their own personal decision about surgery)

A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? a) fidelity b) autonomy c) justice d) nonmaleficence

B (Documenting on a flow sheet prevents duplication of data. The JointCommission does not require duplication of data.)

Boris charts Mr. Scanlini's vital signs and intake and output on a flow sheet.Documenting on a flow sheet ensures duplication of data as required by TheJoint Commission. A. True B. False

2

1. A nurse contacts the health care provider about a change in a patient's condition and receives several new orders for the patient over the phone. When documenting telephone orders in the EHR, what should the nurse do? 1. Print out a copy of all telephone orders entered into the EHR in order to keep them in personal records for legal purposes. 2. "Read back" all telephone orders to the health care provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the EHR. 3. Record telephone orders in the EHR but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. 4. Implement telephone order(s) immediately but insist that the health care provider come to the patient care unit to personally enter the order(s) into the EHR within the next 24 hours.

D (Diagnosis-related groups enable hospitals to be reimbursed a predetermineddollar amount by Medicare)

1. Boris completes Mr. Scalini's admission paperwork. Which of the following establishes reimbursement to the hospital for Mr. Scalini's care? A. Patient care plan B. Joint Commission standards C. Nanda diagnoses D. Diagnosis-related groups

A (Documentation is to be factual, accurate, and thorough. Vague terms do not capture the intent of the reason for documentation.)

1. Cody is going to document in Mr. Brown's medical record. Which of the following is appropriate to document? A. Patient rates headache pain as a 6. Pain is in L temporal area and does not get better with any positioning. B. IV site looks good. C. Voiding without difficulty. D. Is pleasant to care for

a

1. Information regarding a patient's health status may not be released to non-health care team members because: a) legal and ethical obligations require health care providers to keep information strictly confidential b) regulations require health care institutions to document evidence of physical and emotional well-being c) reimbursement issues related to patient care and procedures may be of concern d) fragmentation of nursing medical care procedures may be identified

1, 3, 4

2. You are a nurse who is working in an agency that has recently implemented an EHR. Which of the following are acceptable practices for maintaining the security and confidentiality of EHR information? (Select all that apply.) 1. Using a strong password and changing your password frequently according to agency policy 2. Allowing a temporary staff member to use your computer username and password to access the electronic record 3. Ensuring that work lists (and any other data that must be printed from the EHR) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed 4. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care 5. Remaining logged into a computer to save time if you only need to step away to administer a medication

b

2. a nurse just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paperwork, the nurses needs to record: a) an interpretation of patient behavior b) objective data that are observed c) lengthy entry using lay terminology d) abbreviations familiar to the nurse

4

10. The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation? 1. Health care provider notified about change in assessment of abdominal incision. T. Wright, RN 2. 09-3-21: Notified the surgeon by phone that there is a new area of redness around the patient's incision. T. Wright, RN 3. 1015: Contacted the surgeon and notified about changes in abdominal incision. T. Wright, RN 4. 09-3-21 (1015): Surgeon contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN

B (A factual record such as a patient chart should include descriptive, objective information about what a nurse sees, hears, feels, and smells. Vague terms such as appears and seems state an opinion and not fact. The patient's complaint of pain using the pain-rating scale is a descriptive piece of subjective information that is permissible in the patient's chart.)

2. Boris charts Mr. Scalini's pain assessment in Mr. Scalini's chart. Which of the following is a correct example of charting as it appears in the chart? A. "Patient appears to be free from pain." B. "Patient states a 0 on a pain-rating scale of 1 to 10." C. "Patient seems to be resting comfortably." D. "Patient seems to have pain at the incision site.

C (The Kardex is a summary of the current list of orders, treatments, and diagnostic testing.This form allows the nurse to have all of these together instead of having to go to various places in the medical record.)

2. Cody wants to plan his morning. To which documentation form would Cody refer to find out activity orders, or what treatments Mr. Brown will be receiving today? A. Standardized care plan B. Flow sheet C. Kardex D. Admission history form

c

3. A nurse records that the patient states his abdominal pain is worse now than last night. This is an example of: a) PIE documentation b) SOAP documentation c) narrative charting d) charting by exception

A (Vital signs; pain assessment; administration of medications and treatments; preparation for diagnostic tests or surgery; changes in the patient's status and who was notified; treatment for a sudden change in the patient's status; the patient's response to treatment or intervention; and admission, transfer, discharge, or death of a patient should be documented at the time of occurrence)

3. Boris takes Mr. Scalini's vital signs at 0800. When should Boris chart Mr.Scalini's vital signs? A. At the time of occurrence B. At the end of shift C. Before the lunch break D. At 1200

3

3. When documenting an assessment of a patient's cardiac system in an EHR, the nurse uses the computer mouse to select the "WNL" statement to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80 and 100 beats/min, and regular. Denies chest pain." This is an example of using which of the following documentation formats? 1. Focus charting incorporating data, action, and response (DAR) 2. Problem-intervention-evaluation (PIE) 3. Charting by exception (CBE) 4. Narrative documentation

A, B, D (One of the National Patient Safety Goals provides for standardized communication so there is continuity of care when handing care of a patient over to another caregiver.)

4. At the end of the shift, the registered nurse assigned to Mr. Brown asks Cody if he would give the hand-off report to the nurse coming on who is assigned to Mr. Brown. Which of the following statements are true regarding hand-off reports? (Select all that apply.) A. Provides for the continuity and individualized care of the patient B. Includes up-to-date information and recent changes about the patient C. Must be given face to face between the nurses D. Must include an opportunity for the receiver to ask questions of the person giving the report

d

4. a patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to: a) exchange information among health care providers b) provide information about patient's from one unit to another c) ensure proper care for the patient d) aid in the hospital's quality improvement program.

4 (The patient's medical record should be the most current and accurate continuous source of information about the patient's health care status.)

40. The primary purpose of a patient's medical record is to: 1. Provide validation for hospital charges 2. Satisfy requirements of accreditation agencies 3. Provide the nurse with a defense against malpractice 4. Communicate accurate, timely information about the patient

4 (When recording subjective data, document the patient's exact words within quotation marks whenever possible)

41. Which of the following is correctly charted according to the six guidelines for quality recording? 1. Was depressed today. 2. Respirations rapid; lung sounds clear. 3. Had a good day. Up and about in room. 4. Crying. States she doesn't want visitors to see her like this

2 (An effective change-of-shift report describes each patient's health status and lets staff on the next shift know what care the patients will require.)

42. During a change-of-shift report: 1. Two or more nurses always visit all patients to review their plan of care. 2. The nurse should identify nursing diagnoses and clarify patient priorities. 3. Nurses should exchange judgments they have made about patient attitudes. 4. Patient information is communicated from a nurse on a sending unit to a nurse on a receiving unit.

3 (An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a patient.)

43. An incident report is: 1. A legal claim against a nurse for negligent nursing care 2. A summary report of all falls occurring on a nursing unit 3. A report of an event inconsistent with the routine care of a patient 4. A report of a nurse's behavior submitted to the hospital administration

1, 2, 4

44. You work in a health care agency that uses EHR. Which nursing actions are inappropriate? (Select all that apply.) 1. Allow a temporary staff member to use your computer user name and password. 2. Remain logged into a computer when you leave to administer a medication. 3. Prevent others from seeing a display monitor that contains patient information 4. Allow a health care provider to quickly enter an order using the computer that you are currently logged into to document patient care.

1, 2, 5

5. The nurse who works at the local health care agency is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient's EHR must be printed and faxed to the acute rehabilitation center. Which of the following actions are appropriate for the nurse to take to maintain privacy and confidentiality of the patient's information when faxing this information? (Select all that apply.) 1. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. 2. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. 3. Fax the patient's information without a cover sheet so that the person receiving the information at the acute rehabilitation center can identify it more quickly. 4. After sending the fax, place the information that was printed out in a standard trash can after ripping it into several pieces. 5. After sending the fax, place the information that was printed out in a secure canister marked for shredding.

3

6. The nurse is administering a dose of metoprolol to a patient and is completing the steps of bar-code medication administration within the EHR. As the bar-code information on the medication is scanned, an alert that states, "Do not administer dose if apical heart rate (HR) is <60 beats/min or systolic blood pressure (SBP) is <90 mm Hg" appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system? 1. Electronic health record (EHR) 2. Charting by exception 3. Clinical decision support system (CDSS) 4. Computerized provider order entry (CPOE)

O: 1, 2, 3, 5, 6, 7; S: 4

7. The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O): 1. April 24, 2021 (0900) 2. Repositioned patient on left side. 3. Medicated with hydrocodone-acetaminophen 5/325 mg, 2 tablets PO. 4. "The pain in my incision increases every time I try to turn on my right side." 5. S. Eastman, RN 6. Surgical incision right lower quadrant, 3 inches in length, well approximated, sutures intact, no drainage. 7. Rates pain 7/10 at location of surgical incision.

4

8. The nurse is discussing the advantages of using CPOE with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an EHR? 1. CPOE reduces the time necessary for health care providers to write orders. 2. CPOE reduces the time needed for nurses to communicate with health care providers. 3. Nurses do not need to acknowledge orders entered by CPOE in an EHR. 4. CPOE improves patient safety by reducing transcription errors.

4

9. The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contains an inappropriate abbreviation included on TJC's "do not use" list and should be clarified with the health care provider? 1. Change open midline abdominal incision daily using wet-to-moist normal saline and gauze. 2. Lorazepam 0.5 mg PO every 4 hours prn anxiety 3. Morphine sulfate 1 mg IVP every 2 hours prn severe pain 4. Insulin aspart 8u SQ every morning before breakfast

C (Making this decision about initiating tube feedings is an ethical dilemma as it will have a profound effect on the situation and client, the rest of the choices are LEGAL issues rather than ethical)

A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurse identify as an ethical dilemma? a) a nurse on the med surg unit is demonstrating signs of chemical impairment b) a nurse overhears another nurse telling an older client that is he does not stay in. bed, she will have to apply restraints c) a family has conflicting feelings about the initiation of enteral tube feedings for their father who is terminally ill d) a client who is terminally ill hesitates to name their partner on their durable power of attorney form

c (fairness in care delivery and in the use of resources, by applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining allocation of these scarce resources)

A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? a) fidelity b) autonomy c) justice d) nonmaleficence

d (it is an action that promotes good for others without any self interest, by administering the pain before walking - which could cause pain - the nurse is taking a specific and positive action to help the client.)

A nurse offers pain medication to a client who is postoperative prior tom ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? a) fidelity b) autonomy c) justice d) beneficence

patient's acuity level

Based on the type and number of nursing interventions required by that patient over a 24-hour period

data

D in DAR documentation

interventions that will be used to address the problem

I in PIE documentation

objective

O in SOAP documentation

nursing problem or diagnosis

P in PIE documentation

plan

P in SOAP documentation

d (a commitment to do no harm, administering this medication could harm the client and by questioning it the nurse demonstrates this ethical principle)

a nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? a) fidelity b) autonomy c) justice d) nonmaleficence

diagnosis related groups (DRGs)

classifications based on a patient's primary and secondary medical diagnoses that are used for establishing Medicate reimbursement for patient care provided by a healthcare agency

firewall

combination of hardware and software that protects network resources from outside hackers, network damage, and theft or misuse of information

incident report

completed whenever an incident occurs, helps to ID system and/or human issues in which education or changes in policy need to take place to reduce the risk of future occurences

health information technology (HIT)

computer hardware and software dedicated to the collection, storage, processing, retrieval, and communication of patient care information in a healthcare agency

clinical decision support system

computer program that aids and supports clinical decision making, contains rules and logic statements that link info required for clinical decisions to generate tailored recommendations for individual patients

acuity rating systems

determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours

PIE

documentation that has a specific nursing focus: P = nursing program or diagnosis, I = interventions that will be used to address the problem, E = nursing evaluation

SOAP

documentation used by all healthcare disciplines, S = subjective, O = objective, A = action or nursing intervention

standardized care plans

facilitate the creation/documentation of a nursing plan of care, facilitates safe and consistent care for an identified problem by listing agency standards and EBP guidelines included in the patient's EHR

narrative documentation

format to document patient assessment, clinical decisions, and care provided; consists of a storylike format

flow sheets

graphic record, used by nurses to document patient physiological data and routine care, organized into body systems

case management model

incorporates an inter-professional approach to delivery and documentation of patient care

nursing clinical information system

incorporates the principles of nursing informatics to support the work that nurses do by facilitating documentation of nursing process activities and offering resources for managing nursing care delivery

electronic health record

individual's lifetime computerized record

critical pathways

inter-professional care plans that ID patient problems, key interventions, and expected outcomes within an established time frame, facilitate integration of care

documentation

key communication strategy that produced written account of pertinent patient data, clinical decisions and interventions, and patient responses in a health record

meaningful use

requires that the use of an EHRS results in improved quality, safety, and efficiency of healthcare; increases coordination of health care delivery; advances public health; and safeguards privacy and security of personal health records

nursing informatics

specialty that integrates nursing science, computer science, and information science to manage and communicate data, information knowledge, and wisdom in nursing and informatics practice

computerized provider order entry

system that allows healthcare providers to directly enter standardized, legible, and complete orders for patient care into a medical record from any computer in the HIS

variances

unexpected outcomes and interventions not specified within a critical pathway, occurs when activities on critical pathways are not completed as predicted or a patient does not meet the expected outcomes

Focus charting

uses DAR which addresses the patient concern, D = data, A = action or nursing intervention, R = response of the patient