Documentation and Informatics
Based on the MAR, Nurses' Notes, and Vital Signs tabs, what is the next thing the nurse should say to Davon?
"I can give you acetaminophen now. Your next dose of meperidine can be given in 20 minutes. Would you like the pills now and the shot when it is time?"
Two hours into the shift, the current nurse receives a call from the colleague who cared for Mr. Hilliard the previous shift. The colleague shares that they forgot to document a call to Mr. Hilliard's healthcare provider about a potential surgical wound infection and asks the current nurse to document that information. What is the best response by the current nurse?
"You'll be back tonight, just add it as a late entry."
When discussing a client's condition with the healthcare provider over the phone, the provider asks how many hours passed between the client's last normal temperature and the most recent result.
10 hours
The nurse working the evening shift is recording a blood pressure taken at the time shown on the clock. How is the time written using the 24-hour clock?
20:00
What are the benefits of using an electronic health record (EHR) for the health professional? Select all that apply.
Access to records anytime Ability to document clinical reasoning All data is readily accessible Continuity of care Remote access
Select the objective data present in the documentation below.
Admitted from ED; alert and oriented; moderately short of breath; T 98.4° F (36.9° C)HR 102 RR 23 BP 140/92; SaO2 92% on RA; skin warm/dry, no lesions; PERRLA; bilateral crackles in lungs; heart rate/rhythm regular with occasional irregular beat; JVD present; bilateral pedal edema; abdomen soft, bowel sounds active;
Select the words or phrases within this documentation that are written factually.
Client seeking care of burn on right hand; client states, "My hand hurts like I just gave birth to a watermelon."; fruity smell to breath; unable to walk a straight line; laughing inappropriately; partner and two toddlers at bedside
Complete the statements about the 24-hour clock using the drop-down menu to select the correct word or phrase.
Each new day begins at 00:00 and ends at 23:59 on the same day. Each expression of time using the 24-hour clock uses four digits separated by a colon. The 24-hour clock uses four numbers for all time and the 12-hour clock uses the a.m./p.m. designation.
After a year of planning and saving, Davon (preferred pronouns: she, her) and her partner are taking a well-deserved beach vacation. During their bicycle tour, one of the other sight-seers stops suddenly, causing Davon to swerve and crash. Despite wearing a helmet, Davon loses consciousness. When paramedics arrive, they ask Davon's partner about her health history. What is the best way to provide this information?
Electronically by Davon's partner accessing a copy of her EHR
Identify the improper documentation present in the narrative document below by clicking on it.
Experiencing nausea not relieved by prescribed antiemetic. Primary care provider notified and new medication prescribed.----------S Peters RN
By the time Davon arrives at the emergency department, she has regained consciousness and requests that her healthcare provider send a copy of her health record to the ED via fax. Instead of arriving in the ED, the fax was received on the machine in the business office. The cover sheet identifies the name and phone number of the intended recipient, the name, fax, and phone number of the sender, which are all correct. Unfortunately, two digits in the fax number were typed incorrectly.
In this example, prevention would involve double-checking that the correct fax number of the recipient is correctly placed on the fax cover sheet and double-checking the number typed into the fax machine before hitting the send button. Use of the cover sheet will not prevent mistyping the recipient's fax number, though it can get the fax to the correct recipient more quickly. Programmed speed-dial keys are helpful for frequently dialed numbers, though that may not have applied in this example. Checking the transmittal confirmation sheet to compare the fax number may have meant the error would be discovered sooner, but it would not have prevented it from being sent to the incorrect number.
What are the advantages to clients that are realized by using an electronic health record (EHR)? Select all that apply.
Increased safety Continuity of care
Use the drop-down menus to indicate if the situation presents a potential breach of confidentiality by selecting either Risk Present or No Risk Present on the areas indicated.
Risk Present
Match the definition to the correct term.
The electronic medical record (EMR) is documentation of a single encounter between an individual and a healthcare professional. The electronic health record (EHR) is a longitudinal record of the individual's encounter with multiple health professionals within the healthcare system.
When reviewing Davon's hourly neurovascular checks, which data indicates that something has changed? Select all that apply.
The movement of the arm has not changed because it is immobilized. In addition to the 20:05 changes in edema, color, temperature, capillary refill, sensation, and strength of brachial pulse, the asterisk by the time indicates that something has changed and additional information is contained in the nursing progress notes.
