Exam 25: Documentation in an Electronic Era

The process of obtaining,organizing,and conveying client health information to others in print or electronic format is referred to as

Which of the following is a disadvantage of computerized charting?

A client slipped and fell in the bathroom.When filling out an incident report,the nurse should

All of the following are true about electronic records except

Which of the following is a computer charting system related to predicting client outcomes in home health care?

When completing documentation on each client,the nurse recognizes that documentation serves what purposes?

When documenting client care,the nurse recognizes that which of the following is true about documentation of care?

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?

The nurse recognizes which of the following as a true statement about a nursing classification system?

Which classification system is a comprehensive practice,documentation,and information management tool?

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

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?

One major advantage of an electronic health information technology system is

The nursing diagnosis for a client is immobility related to a stroke.Which classification system can be readily used with this diagnosis?