Question 1

Which of the following is a disadvantage of computerized charting?&#10;A) Ability to aggregate data&#10;B) Improved access to health record&#10;C) Standardized charting&#10;D) Preset activities that can be coded

Accepted Answer

A major drawback for nursing is that use of computerized documentation systems based on medical code numbers often forces nurses to use classification systems designed to describe medical practice instead of describing nursing assessment and care of clients.With this method of charting,the richness of the nursing care provided often goes undocumented.Ability to aggregate data,improved access to health record,and preset activities that can be coded are advantages of computerized charting.

Question 2

The nursing diagnosis for a client is immobility related to a stroke.Which classification system can be readily used with this diagnosis?&#10;A) Omaha system of client problems&#10;B) Clinical pathways&#10;C) Nursing intervention classification&#10;D) International classification of disease (ICD)

Accepted Answer

The nursing intervention classification organizes nursing interventions under domains.The Omaha classification system is used in health departments and home health agencies.Clinical pathways are standards of practice protocols.ICD describes medical practice.

Question 3

A client slipped and fell in the bathroom.When filling out an incident report,the nurse should&#10;A) record complete, pertinent health information.&#10;B) write about the incident report in the client record.&#10;C) store the incident report in the client record.&#10;D) make untimely entries.

Accepted Answer

A mistake to avoid is failing to record complete,pertinent health information.Other mistakes to avoid include making untimely entries and writing about mistakes or incident reports in the client record.Incident reports are stored separately.

Question 4

The nurse is caring for a client who is recovering from an appendectomy.Which of the following coding systems should the nurse use for documenting changing of the client's postoperative abdominal dressing?

A) Nursing outcomes classification (NOC)
B) Diagnostic-related groups
C) Nursing intervention classification
D) North American Nursing Diagnosis (NANDA)

Accepted Answer

The nursing intervention classification organizes nursing interventions under domains.NOC is used to classify outcomes.Diagnostic-related groups code for diagnostic procedures.NANDA describes nursing diagnoses.

Question 5

When documenting client care,the nurse recognizes that which of the following is true about documentation of care?&#10;A) Every nurse should anticipate having clients' records subpoenaed at some time during his or her nursing career.&#10;B) There is a need for quicker documentation that does not reflect the nursing process.&#10;C) The legal assumption is that care was given even if it is not documented.&#10;D) Any method of documentation that provides comprehensive, factual information is legally unacceptable.

Accepted Answer

Every nurse should anticipate having clients' records subpoenaed at some time during his or her nursing career.Management literature emphasizes the need for quicker documentation that still reflects the nursing process.The legal assumption is that the care was not given unless it is documented in the client's record.Any method of documentation that provides comprehensive,factual information is legally acceptable.

Question 6

The nurse recognizes which of the following as a true statement about a nursing classification system?&#10;A) It provides a standard language for nursing care.&#10;B) It promotes visibility and defines professional practice of nursing contributions to client care.&#10;C) It lacks standardized terminologies that promote best practices within nursing.&#10;D) It has not been thoroughly incorporated into many agencies' electronic clinical records.&#10;E) It provides a common language for nursing care.

Accepted Answer

Nursing classification systems provide a standard and common language for nursing care so that nursing contributions to client care become visible and define professional practice.Standardized terminologies allow nursing research to explore nursing interventions and outcomes for common problems to identify "best practices." The ANA says that standards for terminology are an essential requirement for a computer-based patient record.Standardized nursing languages need to convince the business and medical interests managing health care agencies of the need to incorporate nursing classification codes as part of their information technology systems.The greatest problem has been that nursing classifications have not been thoroughly incorporated into many agencies' electronic clinical records.

Question 7

A client is 3 days postoperative from gallbladder surgery secondary to gallstones.Domain: Physiological.Class: Fluid and electrolyte balance.Activity: Check intravenous fluid rate intake every hour.Which of the following nursing coding systems is represented in this situation?

A) North American Nursing Diagnosis (NANDA)
B) Nursing intervention classification
C) Nursing outcome classification
D) Omaha system of client problems

Accepted Answer

The nursing intervention classification identifies nursing interventions that are classified under domains and classes.NANDA is a classification of nursing diagnoses.Nursing outcome classification identifies and classifies nursing-sensitive outcomes of client care.The Omaha system classifies problems under four levels: (1)major domains,(2)specific problems,(3)modifiers,and (4)signs and symptoms.

Question 8

Which classification system is a comprehensive practice,documentation,and information management tool?&#10;A) NANDA&#10;B) NIC&#10;C) NOC&#10;D) Omaha system

Accepted Answer

The Omaha System is a comprehensive practice,documentation,and information management tool.

Question 9

Review the charting sample and determine which documentation error occurred. 1000: Hygienic care given
1100: Complaint of leg pain
1300: Appetite good,resting comfortably

A) Recording on the wrong chart
B) Failure to document an intervention
C) Failure to document a discontinued medication
D) Failure to record outcome of an intervention

Accepted Answer

The nurse failed to document an intervention for the client's complaint of leg pain.The interventions are actions that nurses perform in settings relevant to illness prevention,illness treatment,and health promotion.There is no evidence the nurse has recorded on the wrong chart.There is no evidence the nurse has failed to document a discontinued medication.The nurse has recorded the outcome of an intervention by stating the client has a good appetite and is resting comfortably.

Question 10

When completing documentation on each client,the nurse recognizes that documentation serves what purposes?&#10;A) It communicates to others whether or not care was received.&#10;B) It conveys pertinent information about the client's condition and response to treatment interventions.&#10;C) It substantiates the quality of care by showing adherence to care standards.&#10;D) It provides evidence for reimbursement.&#10;E) It serves as a source of data that can be compiled or aggregated and then analyzed to establish &#34;best practice&#34; interventions.&#10;F) It is not a source for communicating care to others due to HIPAA rules and regulations.

Accepted Answer

Documentation serves five purposes:
.It communicates to others care received or not received.
.It conveys pertinent information about the client's condition and response to treatment interventions.
.It substantiates the quality of care by showing adherence to care standards.
.It provides evidence for reimbursement.
.It serves as source of data that can be compiled or aggregated and then analyzed to establish "best practice" interventions.This includes electronic data,which can be aggregated to monitor outcomes of care processes for quality improvement,a QSEN competency.

Question 11

The process of obtaining,organizing,and conveying client health information to others in print or electronic format is referred to as&#10;A) narration.&#10;B) documentation.&#10;C) care coordination.&#10;D) order entry.

Accepted Answer

The answer of The process of obtaining,organizing,and conveying client health...

Question 12

All of the following are true about electronic records except&#10;A) they are portable.&#10;B) they are less durable than paper charting.&#10;C) they are easily transferable.&#10;D) they are more durable than paper charting.

Accepted Answer

The answer of All of the following are true about...

Question 13

Which of the following is a computer charting system related to predicting client outcomes in home health care?&#10;A) EHR&#10;B) OASIS&#10;C) NANDA&#10;D) HIPAA

Accepted Answer

The answer of Which of the following is a computer...

Question 14

One major advantage of an electronic health information technology system is&#10;A) lack of integration.&#10;B) accessibility of health records.&#10;C) it is not easily transferable.&#10;D) it consists of imaging files that allow for delayed access.

Accepted Answer

The answer of One major advantage of an electronic health...

Deck 25: Documentation in an Electronic Era