Question 1

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.

Accepted Answer

To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patient's bedside to facilitate immediate documentation of information as it is collected. A good system requires frequent, random changes in personal passwords to prevent unauthorized persons from tampering with records. When using a health care agency computer system, it is essential that you do not share your computer password with anyone under any circumstances. You destroy all papers containing personal information immediately after you use them. Taking nursing notes home is a violation of the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality.

Question 2

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.

Accepted Answer

When the staff make an incorrect statement, then the nurse needs to follow up. Competence in informatics is not the same as computer competency. All the rest are correct information so the nurse does not need to follow up. To become competent in informatics, you need to be able to use evolving methods of discovering, retrieving, and using information in practice. This means that you learn to recognize when information is needed and have the skills to find, evaluate, and use that information effectively. Nursing informatics is a specialty that integrates the use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research.

Question 3

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

Accepted Answer

When you are a student in a clinical setting, confidentiality and compliance with HIPAA are part of professional practice. Reading the progress notes of an assigned patient's record and giving a change-of-shift report to the oncoming nurse about the patient are behaviors that follow HIPAA and confidentiality guidelines. Do not share information with other patients or health care team members who are not caring for a patient. Not only is it unethical to view medical records of other patients, but breaches of confidentiality lead to disciplinary action by employers and dismissal from work or nursing school. To protect patient confidentiality, ensure that written materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information), and never print material from an electronic health record for personal use.

Question 4

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.

Accepted Answer

The answer of A nurse is using focused charting. Match...

Question 5

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

Accepted Answer

One design model for Nursing Clinical Information Systems (NCIS) is the protocol or critical pathway design. This design facilitates interdisciplinary management of information because all health care providers use evidence-based protocols or critical pathways to document the care they provide. The knowledge base within a CDSS contains rules and logic statements that link information required for clinical decisions in order to generate tailored recommendations for individual patients, which are presented to nurses as alerts, warnings, or other information for consideration. The nursing process design is the most traditional design for an NCIS. This design organizes documentation within well-established formats such as admission and postoperative assessments, problem lists, care plans, discharge planning instructions, and intervention lists or notes. Computerized provider order entry (CPOE) systems allow health care providers to directly enter orders for patient care into the hospital's information system.

Question 6

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.

Accepted Answer

Focused charting uses the DAR format: Data, Action, and Response. Choice B is the Response, as it describes the outcome or response of the patient after interventions have been made.

Question 7

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).

Accepted Answer

When faxing, use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. An automatic sign-off is a safety mechanism that logs a user off the computer system after a specified period of inactivity. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information. All papers containing PHI (e.g., Social Security number, date of birth or age, patient's name or address) must be destroyed immediately after you use or fax them. Most agencies have shredders or locked receptacles for shredding and incineration. Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. A firewall is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information and should not be bypassed.

Question 8

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

Accepted Answer

Advantages associated with the nursing information system include reduced errors of omission; better access to information (not more time to read charts); enhanced quality of documentation; reduced, not increased, hospital costs; increased nurse job satisfaction; compliance with requirements of accrediting agencies (e.g., TJC); and development of a common, not varied, clinical database.

Question 9

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

Accepted Answer

A patient's record is a valuable source of data for all members of the health care team. Its purposes include interdisciplinary communication, legal documentation, financial billing (reimbursement), education, research, and auditing/monitoring. Nursing process is a way of thinking and performing nursing care; it is not a purpose of a health care record.

Question 10

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.

Accepted Answer

Nurses' documentation practices in home health, long-term care, and hospitals can determine reimbursement for health care. A "near miss" is an incident where no property was damaged and no patient or personnel were injured, but given a slight shift in time or position, damage or injury could have easily occurred. A clinical information system (CIS) does not have to be installed by 2014 to obtain reimbursement. CIS programs include monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems. Diagnosis-related groups (DRGs) are the basis for establishing reimbursement for patient care, not HIPAA. Legislation to protect patient privacy regarding health information is the Health Insurance Portability and Accountability Act (HIPAA).

Question 11

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.

Accepted Answer

Accurately documenting services provided, including the supplies and equipment used in a patient's care, clarifies the type of treatment a patient received. This documentation also supports accurate and timely reimbursement to a health care agency and/or patient. None of the other options had equipment or supplies listed. Avoid using generalized, empty phrases such as "status unchanged" or "had good day." Do not enter personal opinions-stating that the patient is cooperative is a personal opinion and should be avoided. "Finally, patient had no complaints" is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care.

Question 12

Which entry will require follow-up by the nurse manager? 
A) 0800
B) 0810
C) 0815
D) 0830

Accepted Answer

Do not include any reference to an incident in the medical record; therefore, the nurse manager must follow up. A notation about an incident report in a patient's medical record makes it easier for a lawyer to argue that the reference makes the incident report part of the medical record and therefore subject to attorney review. When an incident occurs, document an objective description of what happened, what you observed, and the follow-up actions taken, including notification of the patient's health care provider in the patient's medical record. Remember to evaluate and document the patient's response to the incident.

Question 13

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.

Accepted Answer

The chart entry includes the acronym "ASI," which stands for Applied, Stayed, Instructed. This indicates that the nurse applied oxygen, stayed with the patient, and instructed them to slow their breathing.

Answer: B
 The chart entry includes the acronym "SOAP," which stands for Subjective, Objective, Assessment, Plan. This indicates that the patient stated they feel better subjectively, and the nurse recorded objective data such as respirations and oxygen saturation.

Answer: C
 The chart entry does not include an acronym, as none of the commonly used acronyms apply to the information provided. The nurse simply documented the patient's complaint of chest pain and difficulty breathing, along with confusion.

Question 14

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.

Accepted Answer

The nurse receiving a TO or VO enters the complete order into the computer using the computerized provider order entry (CPOE) software or writes it out on a physician's order sheet for entry in the computer as soon as possible. After you have taken the order, read the order back, using the "read back" process, and document that you did this to provide evidence that the information received (such as call back instructions and/or therapeutic orders) was verified with the provider. An example follows: "10/16/2015 (08:15), Change IV fluid to Lactated Ringers with Potassium 20 mEq/L to run at 125 mL/hr. TO: Dr. Knight/J. Woods, RN, read back." VO stands for verbal order, not telephone order. The health care provider's name and read back must be included in the chart entry.

Quiz 26: Documentation and Informatics

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

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

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

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

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

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

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

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

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

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