ATI 7: Documentation
A nurse is reviewing documentation principle with a group of newly hired assistance personnel (SP). Which of the following information should the nurse include?
A nurse who delegates a tasks to an AP will review the charting for that task
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 promotes information sharing among members of the interdisciplinary team
A newly licensed license is orienting to a facility's documentation system. The facility requires staff to only 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 staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicated an understanding of the information?
I can take telephone prescription if a provider is directing a code for an unresponsive client
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 nurse is preparing to administer morphine 15mg PO every 4 hours 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 nurse is discussing computerized provider order entry (CPOE) 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 their electronic health record (EHR) 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 is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on the Joint Comission's Do Not Use List? (Select all that apply)
MSO4, IU, qhs
A nurse is caring for a client following 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 form the client first? (Select all the apply)
The admitting provider, The charge nurse on the unit, and the client
A nurse in a clinic is reviewing a client's 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 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 provider's office. Which of the following characteristics should the charge nurse plan to include? (Select all that apply)
Reduces medical errors, Makes client medical history more easily available, and increases accuracy of coding procedures
A nurse manager is reviewing the documentation of four newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly?
Synthroid 100 mg PO morning every morning ac
A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on exertion." Which of the following documentation formats describes this entry?
The "S" in SOAP
A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which if the following agencies advocated for nationwide use of EHRs?
The Institute of Medicine
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries should the nurse identify as meeting the American Nurses Association (ANA) standards for documentation?
The client vomited 240 mL of clear emesis but denies pain or nausea
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 information should the nurse include as a benefit of electronic documentation?
The system alerts providers of possible actions that could cause client harm
