Deck 8: The Patients Chart or Electronic Medical Record

Question 1

Anna Jensen and Anna Johnson are both patients on the nursing unit.While stuffing Anna Jensen's chart,the HUC mistakenly used Anna Johnson's ID labels to label the forms.No specific patient information appears on these mislabeled forms.What should the HUC do to correct the error?

A)Complete an incident report because this error falls outside of the norm for this task.
B)Once it has been established that no patient information is noted on the forms,the incorrectly stamped forms may be shredded.
C)Place correct ID labels over the incorrect labels,and reuse the forms.
D)Peel off the ID labels as much as possible,and once the labels are removed,the form may be reused.

Answer 1

Once it has been established that no patient information is noted on the forms,the incorrectly stamped forms may be shredded.

Question 2

The health unit coordinator (HUC)would view the patient's chart as primarily:

A)a means of communication between the doctor and the hospital staff.
B)a means of billing the insurance company.
C)material for medical fiction books.
D)interesting reading for staff members.

Answer 2

a means of communication between the doctor and the hospital staff.

Question 3

Which of the following is TRUE regarding the copying of a patient paper medical record?

A)The HUC in training may make copies of a patient chart to take home to study.
B)Copies of the chart may be made to send with a patient who is discharged to another health care facility.
C)A copy of a patient's record may be made for any hospital employee who requests one.
D)If a patient is transferred to a hospital out of state,the original patient record is sent to the receiving hospital.

Answer 3

Copies of the chart may be made to send with a patient who is discharged to another health care facility.

Question 4

The Admission Service Agreement or Conditions of Admission contains:

A)doctors' orders.
B)advance directives regarding the patient's health care decisions.
C)legal permission to treat the patient and a financial agreement.
D)the patient's address,next of kin,and admission diagnosis.

Question 5

Guidelines for writing on a patient's paper chart include which of the following?

A)Entries may be made in pen or pencil.
B)A written error made on a patient chart form may be erased or obliterated.
C)All written entries on patient chart forms must include the date and time.
D)The HUC may rewrite doctors' orders if the doctor's handwriting is difficult to read.

Question 6

The procedure for correcting an error on a patient's chart form that is incorrectly labeled with another patient's ID label is to:

A)place the correct patient's ID label over the incorrect label.
B)peel the incorrect ID label off and replace it with the correct label.
C)draw an X across the incorrect label,record information as one would when a written entry is made,and place the correct label next to the incorrect label.
D)shred the form,obtain a new form,and label with the correct label.

Question 7

NINP written on a label affixed to a patient's chart means that the:

A)patient is also being attended to by a nurse practitioner.
B)patient has a name that is similar to that of another patient on the unit.
C)patient has an advance directive that spells out no intravenous (IV),no parenteral fluids.
D)patient's admission should not be published or publicized.

Question 8

Guidelines for entering information into the patient's EMR include:

A)All nurses' notes must be scanned into the patient's EMR.
B)The HUC must type all doctors' orders into the patient's EMR.
C)The HUC must scan all handwritten doctors' orders into the patient's EMR.
D)Handwritten progress notes,electrocardiograms (EKGs),and outside records and reports must be scanned into the patient's EMR.

Question 9

A surgery (or procedure)consent form,a legal agreement,is prepared by the HUC prior to the patient's surgery or invasive procedure.Which of the following is TRUE regarding this form?

A)The patient may sign a procedure consent form prior to being informed of associated risks or the expected outcome.
B)Abbreviations are commonplace in a hospital;the HUC may use hospital-approved abbreviations when preparing a surgical or medical procedure consent form.
C)The HUC is the staff member who is responsible for obtaining the patient's signature on a consent form.
D)When the EMR is used,a signed surgical or medical procedure consent form is scanned into the patient's EMR.

Question 10

A patient's old record refers to:

A)a senior citizen's record that exceeds 10 years of age.
B)calling the patient's doctor to obtain date(s)of previous admission(s).
C)asking the patient to provide date(s)of previous admission(s).
D)calling or sending a request to HIMS to obtain the patient's records from a previous admission.

Question 11

A patient's chart is labeled with name alert when:

A)a patient has celebrity status.
B)a patient is an employee of the hospital.
C)two patients on a nursing unit have similarly spelled last names (or the same name).
D)a patient's name is similar to his or her doctor's name.

Question 12

The patient is receiving medication because his blood sugar is regularly too high.The nurse is required to check his blood sugar at regular intervals.When paper charts are used,this information will be written on the:

A)parenteral fluid or infusion record.
B)therapy record.
C)diabetic record.
D)anticoagulant therapy record.

Question 13

When thinning a chart,it is acceptable practice to:

A)send thinned out chart forms to the health information management system department (HIMS)prior to the patient's discharge.
B)discard or shred selected records from the earliest part of the admission.
C)transfer thinned out records with the patient's chart if the patient is sent to another unit.
D)place thinned out records into another binder alongside the current record in the chart rack.

Question 14

"Stuffing" charts refers to:

A)ordering routine diagnostic tests that were not ordered for the patient to legally protect the doctor.
B)the registered nurse (RN)documenting more than is necessary in the nurses' notes.
C)placing all charts in proper sequence in the chart rack when not in use.
D)placing new chart forms in each patient's chart before the need arises.

Question 15

Legal rules governing proper obtaining of a surgical or medical invasive procedural consent include which of the following?

A)The patient may sign if under legal age if he or she is mature and understands the procedure.
B)The consent is legally valid if the patient has been administered mind-clouding medications.
C)The patient must be mentally competent.
D)If the doctor has thoroughly explained the procedure,it is not necessary to have a witness to the patient's signing the consent form.

Question 16

If you see 2400 noted in a patient's chart as the time when a patient was given a drug,this means that:

A)the nurse was obviously sidetracked,because this does not refer to any time.
B)it has been 24 hours since the patient was last given the drug.
C)the patient was given the drug at noon.
D)the drug was given at midnight,and this was recorded using military time.

Question 17

A patient's history and physical (H&P)chart form will include:

A)the patient's medical history,present symptomatic history,and physical assessment.
B)the patient's name,address,employment,insurance,and next of kin.
C)the patient's vital signs for a number of days.
D)all medications given by nursing personnel during a patient's admission.

Question 18

A patient's height and weight will be found on which chart form?

A)Admission and service agreement form
B)Face sheet
C)CQI
D)Nurses' admission record

Question 19

The paper admission packet contains patient forms typical for each patient hospital encounter.Which of the following forms is used for each patient admission?

A)Anticoagulant therapy record
B)Diabetic record
C)Nurses' admission record
D)Consultation form

Question 20

When the EMR with computerized physician order entry (CPOE)is used,an error in treatment:

A)must be documented in the patient's EMR and an incident report must be completed.
B)must be documented on an incident report but may be deleted from the EMR.
C)may be deleted from the EMR,and an incident report is not necessary.
D)must be documented in the patient's EMR,but an incident report is not necessary.

Question 21

The term clinical pathway refers to:

A)a plan of care that includes the physician's orders and predicted outcomes.
B)a computer menu of order options.
C)the distance from the admitting department to the nursing unit a patient is admitted to.
D)the name of the hospital newsletter.

Question 22

When military time is used to enter a notation on a patient's chart,1700 would indicate what time in standard time?

A)3:00 PM
B)7:00 PM
C)5:00 PM
D)7:00 AM

Question 23

A locked workstation that is located on the wall outside a patient's room is called a:

A)pen tab.
B)WALLaroo.
C)WALKaroo.
D)cluster of workstations (COW).

Question 24

When military time is used to enter a notation on a patient's chart,12:30 AM is written:

A)1230.
B)2030.
C)2230.
D)2430.

Question 25

Which of the following abbreviations may be noted on the patient's medication administration record (MAR)?

A)Hx
B)H&P
C)DRG
D)NKDA

Question 26

Charting vital signs and other data accurately and in a timely manner is important so the information is readily available to:

A)the patient's case manager.
B)the patient's family.
C)the incoming HUC.
D)the patient's doctor.

Question 27

A patient who refuses a blood transfusion would be asked to:

A)sign a refusal to permit blood transfusion.
B)change their mind.
C)talk to a psychiatrist.
D)sign a consent to receive a blood transfusion.

Question 28

A parenteral fluid record is placed in a patient's chart when the patient is:

A)receiving medication.
B)receiving IV fluids.
C)recovering from surgery.
D)having his or her vital signs taken frequently.

Question 29

Which of the following would be legal to write on a patient's surgical consent form?

A)Lumpectomy lt breast
B)Removal of a lump from lt breast
C)Lt breast lumpectomy
D)Lumpectomy left breast

Question 30

To correct an error in a written entry on a chart form,the HUC would:

A)record the error and write mistaken entry,along with date,full name,and status in a blank area near the error.
B)recopy the chart form,leaving out the error,and sign,date,and indicate the time.
C)use white-out on the error and rewrite the correct entry.
D)draw a single line through the error,and write mistaken entry along with date,first initial,last name,and status;then write the correct entry.

Question 31

Supplemental forms are placed in a patient's paper chart when:

A)the patient's doctor requests them.
B)specific conditions or events dictate their use.
C)the nurse determines that they are necessary.
D)the HIMS department requires their use.

Question 32

For patients who receive physical therapy,notes regarding their progress would be recorded on the:

A)therapy record.
B)doctors' progress notes.
C)nurses' progress notes.
D)consultation form.