Exam 26: Documentation and Informatics

A nurse is discussing the advantages of standardized documentation forms in the nursing information system.Which advantage should the nurse describe?

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

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 developed the following discharge summary sheet.Which critical information should be added?

A nurse is preparing a change-of-shift report for a patient who had chest pain.Which information is critical for the nurse to include?

A nurse is giving a hand-off report to the oncoming nurse.Which information is critical for the nurse to report?

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

A nurse wants to integrate all pertinent patient information into one record,regardless of the number of times a patient enters the health care system.Which term should the nurse use to describe this system?

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

A nurse is charting on a patient's record.Which action is most accurate legally?

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 creating a plan to reduce data entry errors and maintain confidentiality.Which guidelines should the nurse include?

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

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

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 nurse wants to reduce data entry errors on the computer system.Which behavior should the nurse implement?

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 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 nurse is using the source record and wants to find the daily weights.Where should the nurse look?