EAQ CH 26: INFORMATICS AND DOCUMENTATION

The nurse, after administering antibiotics, is updating a patient's chart in the emergency department. Which elements of the report does the nurse accurately document to limit nursing liability in case of a legal claim? Select all that apply. - Current medications given - Discontinued medications - Drug allergies - Name of drug manufacturer - Size, shape, and color of the pills

- current medications given - discontinued medications - drug allergies

which information would the nurse include in a patient discharge summary forms? select all that apply - dietary restrictions -follow up care - emergency contact numbers - preoperative instructions - acuity records

- dietary restrictions -follow up care - emergency contact numbers

which point would the manager emphasize when teaching nursing staff on the importance of security with the implementation of the electronic health record (EHR)? select all that apply - do not share passwords with anyone - do not leave the patient's medical record open unattended on a computer screen - do not log into the patient's database - do not print information with personal health information (PHI) - do not log in with someone else's user access

- do not share passwords with anyone - do not leave the patient's medical record open unattended on a computer screen - do not log in with someone else's user access

which outcome is expected after effective documentation? select all that apply - reduction of the level of care required - facilitation of proper insurance reimbursement - efficient use of time -enhanced community of care -protection for the nurse from legal recourse

- facilitation of proper insurance reimbursement - efficient use of time -enhanced community of care -protection for the nurse from legal recourse

which statement describes the purpose of the incident report? select all that apply - identifies loopholes in the operation of the health care system - provides good, quality health care -documents a patient's negative feedback related to the health care delivered - determines the severity of the punishment to be delivered -identifies the need to change a procedure or policy

- identifies loopholes in the operation of the health care system - provides good, quality health care -identifies the need to change a procedure or policy

which element is integral to the SOAP note? select all that apply - intervention - order - subjective - assessment - problem

- subjective - assessment

a senior nurse is reviewing a nurses documentation of a patient with pneumonia, "blood pressure is 150/90 mm Hg; pulse is 92 beats per minute, and the respiratory rate is 22 breaths per minute. the patient seems to have difficulty breathing. sounds are produced when the patient exhales. Auscultation reveals rhonchi in the lower lung bases. copious amounts of phlegm have been produced since morning." which statement in the documentation is considered to be poor quality documentation and informatics? select all that apply - vital signs: blood pressure 150/90 mmHg, pulse rate 92 beats per minute, and respiration 22 breaths per minute. - the patient seems to have difficulty breathing - auscultation reveals rhonchi in the lower lung bases - sounds are produced when exhaling - copious amounts of sputum produced since morning

- the patient seems to have difficulty breathing - sounds are produced when exhaling - copious amounts of sputum produced since morning

which information would the nurse include in a hand-off report at the end of shift? select all that apply - the patient's name, age, and admitting diagnosis -allergies to food and medication - personal evaluation that the patient is "needy" - how much the patient ate for breakfast - that the patient's pain rating went from an 8 to a 2 on a scale of 1 to 10 after receiving 650 mg of acetaminophen.

- the patient's name, age, and admitting diagnosis -allergies to food and medication - that the patient's pain rating went from an 8 to a 2 on a scale of 1 to 10 after receiving 650 mg of acetaminophen.

which is the mode for exchanging information among members of the health care team? select all that apply. - pictures - a thesis -written reports -oral communication -electronic cards

- written reports - oral communication

which guidance would the nurse provide when teaching students about legal guidelines for documentation? select all that apply -record all facts -correct all errors promptly -chart only for yourself -document critical comments about patients -use shorthand when necessary to speed your documentation

-record all facts -correct all errors promptly -chart only for yourself

which standardized assessment tool is used for receiving health care funding from the Centers for Medicare and Medicaid Services? Select all that apply -resident assessment instrument (RAI) -minimum data set (MDS) -critical pathways -variance -acuity report

-resident assessment instrument (RAI) -minimum data set (MDS)

the health care provider calls in a prescription for 10 mg of morphine every 4 hours for a patient's postoperative pain. which action does the nurse take to record and follow these instructions? Select all that apply -the nurse administers 10 mg of morphine every 4 hours and documents it. -the nurse reads back the prescription to the health care provider for verification and documents that the prescription was read back -the nurse records the details of the instructions and marks it as a telephone order (TO) -the nurse confirms the patient's name, room number, and diagnosis -the nurse notes on the chart that medication was administered "as per orders"

-the nurse administers 10 mg of morphine every 4 hours and documents it. -the nurse reads back the prescription to the health care provider for verification and documents that the prescription was read back -the nurse records the details of the instructions and marks it as a telephone order (TO) -the nurse confirms the patient's name, room number, and diagnosis

The nurse is given a form with preset standard findings for recording a progress note. The nurse reports the findings in the following way: "Physical Exam: All systems within normal except left lower extremity, casted d/t to heel fracture. Review of Systems: All normal except pain in the left foot." What kind of documentation and informatics is this? A. Charting by exception B. DAR (data, action of nursing intervention, and response of the patient) report C. PIE (problem, intervention, and evaluation) report D. Narrative report

A. charting by exception

which system in the electronic health record (EHR) provides warnings to alert a health care provider of patient allergies when prescribing medications? a. administrative information system b. computerized provider order entry (CPOE) c. clinical decision support system (CDSS) d. clinical information system (CIS)

C. clinical decision support system (CDSS)

which statement indicates that the nurses understand the major advantage of using computerized provider order entry (CPOE)? a. "transcription errors are reduced when using CPOE" b. "the use of CPOE reduces the amount of time it takes health care providers to write prescriptions" c. "health care providers can write prescriptions from any computer that has internet access." d. "CPOE reduces the time nurses use to communicate with health care providers"

a. "transcription errors are reduced when using CPOE"

a critical pathway for an orthopedic unit indicates that a patient should be afebrile, normotensive, and eupneic after knee-replacement surgery. the nurse performs a postoperative examination of a patient's status after left knee-replacement surgery and finds that the patient is experiencing a low-grade temperature. which term describes this finding? a. variance b. positive variance c. negative variance d. critical finding

a. variance

The ability to review patient education provided by other nurses is common in which type of record system? a. information technology b. electronic health record c. personal health information d. administrative information system

b. electronic health record

which response by the nurse is accurate for a patient requesting a copy of his or her medical record? a. state that only family may read the record b. indicate that he or she has the right to read the record c. tell him or her that he or she is not allowed to read the record d. explain that only health care workers have access to the record

b. indicate that he or she has the right to read the record

which section of the traditional source record does the nurse use to record patient demographic information? a. nurse's notes b. patient care summary c. graphic sheet and flow sheet d. nurse's admission assessment

b. patient care summary

at the end of a shift, the nurse documents a patient's condition, anticipated condition, medications, and nursing interventions fullfilled so that the next nurse can follow the appropriate treatment plan and care for the patient. this describes which type of report? a. discharge summary b. incident report c. hand-off report d. telephone report

c. hand off report

A health care organization has incorporated information and computer technology. which system will help the organization comply with the requirement of accrediting agencies? a. nursing documentation system b. clinical decision support system c. nursing clinical information system d. bar-code medication administration system

c. nursing clinical information system

which method is appropriate for the nurse to dispose of printed patient information? a. rip several times and place in standard trash can b. place in the patient's paper based chart c. place in a secure canister marked for shredding d. burn the documents

c. place in a secure canister marked for shredding

The health care provider prescribes a clear liquid diet for a patient with gastritis. On the first day, the patient consumes soup and tolerates it well. How does the nurse document this finding? a. the patient had soup and tolerated it well b. the patient had soup while watching a football game c. the patient had 2 cups of soup, which was tolerated well d. the patient had soup, 2 cp and was w.1., w.a.p.

c. the patient had 2 cups of soup, which was tolerated well

which place is appropriate to document urine output in the patient's chart? a. admission sheet b. operative report c. physician's prescription sheet d. flow sheet

d. flow sheet

where does the nurse access the information to contact the guardian of a patient? a. discharge summary b. nurse's admission assessment c. nurse's notes d. patient care summary

d. patient care summary

in which section would the nurse place subjective and objective data? a. care plan b. database c. problem list d. progress notes

d. progress notes