Deck 26: Documentation and Informatics

Question 1

A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse find?

A) Electronic medical record
B) Electronic health record
C) Electronic charting record
D) Electronic problem record

Answer 1

Electronic health record

Question 2

A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene?

A) The student nurse reads the patient's plan of care.
B) The student nurse reviews the patient's medical record.
C) The student nurse shares patient information with a friend.
D) The student nurse documents medication administered to the patient.

Answer 2

The student nurse shares patient information with a friend.

Question 3

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?

A) Status unchanged, doing well
B) Patient seems to be in pain and states, "I feel uncomfortable."
C) Left knee incision 1 inch in length without redness, drainage, or edema
D) Patient is hard to care for and refuses all treatments and medications. Family is present.

Answer 3

Left knee incision 1 inch in length without redness, drainage, or edema

Question 4

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?

A) Add this data to the problem list.
B) Focus chart using the DAR format.
C) Document the variance in the patient's record.
D) Report a positive variance in the next interdisciplinary team meeting.

Question 5

A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting?

A) Patient went up and down stairs
B) Demonstrated use of crutches
C) Used crutches with no difficulties
D) Deficient knowledge related to never using crutches

Question 6

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing?

A) A minimum data set
B) An admission assessment and acuity level
C) A focused assessment/specific body system
D) An intake assessment form and auditing phase

Question 7

A nurse is completing an OASIS data set on a patient. The nurse works in which area?

A) Home health
B) Intensive care unit
C) Skilled nursing facility
D) Long-term care facility

Question 8

A nurse developed the following discharge summary sheet. Which critical information should the nurse add?

A) Clinical decision support system
B) Admission nursing history
C) Mode of transportation
D) SOAP notes

Question 9

A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record?

A) Nursing process form
B) Step-by-step skills manual
C) A list of possible procedures
D) Reports to third-party payers

Question 10

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient?

A) Upon admission
B) Right before discharge
C) After the congestion is treated
D) When the primary care provider writes the order

Question 11

A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete?

A) A verbal report
B) An electronic record entry
C) A referral
D) An acuity rating

Question 12

A patient is being discharged home. Which information should the nurse include?

A) Acuity level
B) Community resources
C) Standardized care plan
D) Signature for verbal order

Question 13

A nurse is preparing to document a patient who has chest pain. Which information is critical for the nurse to include?

A) The family is a "pain."
B) Pupils equal and reactive to light
C) Had poor results from the pain medication
D) Sharp pain of 8 on a scale of 1 to 10

Question 14

A nurse wants to find the daily weights of a patient. Which form will the nurse use?

A) Database
B) Progress notes
C) Patient care summary
D) Graphic record and flow sheet

Question 15

A nurse is charting. Which information is critical for the nurse to document?

A) The patient had a good day with no complaints.
B) The family is demanding and argumentative.
C) The patient received a pain medication, Lortab.
D) The family is poor and had to go on welfare.

Question 16

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking?

A) Determining the degree to which standards of care are met by reviewing patients' health records
B) Realizing that care not documented in patients' health records still qualifies as care provided
C) Basing reimbursement upon the diagnosis-related groups documented in patients' records
D) Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment

Question 17

A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to follow up?

A) The new nurse documents only for self.
B) The new nurse charts consecutively on every other line.
C) The new nurse ends each entry with signature and title.
D) The new nurse keeps the password secure.

Question 18

A nurse is providing care to a group of patients. Which situation will require the nurse to obtain a telephone order?

A) As the nurse and health care provider leave a patient's room, the primary care provider gives the nurse an order.
B) At 0100, a patient's blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood.
C) At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order.
D) A nurse reads an order correctly as written by the health care provider in the patient's medical record.

Question 19

After providing care, a nurse charts in the patient's record. Which entry will the nurse document?

A) Appears restless when sitting in the chair
B) Drank adequate amounts of water
C) Apparently is asleep with eyes closed
D) Skin pale and cool

Question 20

A nurse is charting on a patient's record. Which action will the nurse take that is accurate legally?

A) Charts legibly
B) States the patient is belligerent
C) Writes entry for another nurse
D) Uses correction fluid to correct error

Question 21

A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take?

A) Use the same password all the time.
B) Share password with only one other staff member.
C) Print out and review computer nursing notes at home.
D) Chart on the computer immediately after care is provided.

Question 22

A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up?

A) To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice.
B) A nurse needs to know how to find, evaluate, and use information effectively.
C) If a nurse has computer competency, the nurse is competent in informatics.
D) Nursing informatics is a recognized specialty area of nursing practice.

Question 23

Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)

A) Writes the patient's room number and date of birth on a paper for school
B) Prints/copies material from the patient's health record for a graded care plan
C) Reviews assigned patient's record and another unassigned patient's record
D) Gives a change-of-shift report to the oncoming nurse about the patient
E) Reads the progress notes of assigned patient's record
F) Discusses patient care with the hospital volunteer

Question 24

A nurse is using focused charting. Match the chart entry to the correct letter of the acronym.

D

A)Applied oxygen, stayed with patient, and instructed to slow breathing.
B)Patient states, "feel better," respirations 16 with O₂ saturations 96%.
C)Patient states, "can't catch my breath and chest hurts." Confused.

Question 25

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using?

A) Clinical decision support system
B) Nursing process design
C) Critical pathway design
D) Computerized provider order entry system

Question 26

A nurse is using focused charting. Match the chart entry to the correct letter of the acronym.

R

A)Applied oxygen, stayed with patient, and instructed to slow breathing.
B)Patient states, "feel better," respirations 16 with O₂ saturations 96%.
C)Patient states, "can't catch my breath and chest hurts." Confused.

Question 27

A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)

A) Bypass the firewall.
B) Implement an automatic sign-off.
C) Create a password with just letters.
D) Use a programmed speed-dial key when faxing.
E) Impose disciplinary actions for inappropriate access.
F) Shred papers containing personal health information (PHI).

Question 28

A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe?

A) Varied clinical databases
B) Reduced errors of omission
C) Increased hospital costs
D) More time to read charts

Question 29

A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.)

A) Communication
B) Legal documentation
C) Reimbursement
D) Nursing process
E) Research
F) Education

Question 30

A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session?

A) Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care.
B) A clinical information system must be installed by 2014 to obtain health care reimbursement.
C) A "near miss" helps determine reimbursement issues for health care.
D) HIPAA is the basis for establishing reimbursement for health care.

Question 31

A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement?

A) Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.
B) Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints.
C) Breathing without difficulty. Sitting up in bed watching TV. Had a good day.
D) Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.

Question 32

Which entry will require follow-up by the nurse manager?

A) 0800
B) 0810
C) 0815
D) 0830

Question 33

A nurse is using focused charting. Match the chart entry to the correct letter of the acronym.

A

A)Applied oxygen, stayed with patient, and instructed to slow breathing.
B)Patient states, "feel better," respirations 16 with O₂ saturations 96%.
C)Patient states, "can't catch my breath and chest hurts." Confused.

Question 34

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?

A) 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.
B) 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back.
C) 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.
D) 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN.