Deck 25: E-Documentation in Health Information Technology Systems

Question 1

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

A) Every nurse should anticipate having patients' records subpoenaed at some time during his or her nursing career.
B) There is a need for quicker documentation that does not reflect the nursing process.
C) The legal assumption is that care was given even if it is not documented.
D) Any method of documentation that provides comprehensive, factual information is legally unacceptable.

Answer 1

Every nurse should anticipate having patients' records subpoenaed at some time during his or her nursing career.

Question 2

What term is used to identify the process of obtaining, organizing, and conveying patient health information to others in print or electronic format?

A) Narration.
B) Documentation.
C) Care coordination
D) Order entry

Answer 2

Documentation.

Question 3

Which nursing classification system used internationally is the best researched and most widely implemented?

A) Omaha System
B) ICD-10
C) NANDA-I
D) NIC/NOC

Answer 3

NANDA-I

Question 4

rWhich of these engages patients as partners in health care, is an expectation at the beginning staff nurse job level, and is among items tested on licensure exams?

A) CPOE
B) HIT
C) EHR
D) LPCs

Question 5

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

A) EHR
B) OASIS
C) NANDA
D) HIPAA

Question 6

Which pair best describes two key elements of collaborative work in nursing?

A) Communication and documentation
B) Portability and ease of access
C) Clarity and efficiency
D) Flow sheets and longitudinal plans of care

Question 7

What statement is accurate when describing characteristics of an electronic health information technology system?

A) It lacks the capacity to bring about integration.
B) It provides accessibility to multiple health records.
C) It presents challenges in the transfer of patient information.
D) It consists of imaging files that allow for delayed access.

Question 8

What is the advantage of coding in the use of electronic health records (EHRs)?

A) It makes documenting at the bedside 'warmer' in a human relations sense.
B) It allows the development of data for multiple levels of accountability, including for individual nurses, units, or agencies.
C) It allows information to be communicated and extracted from EHRs.
D) It guarantees that nursing care meets the requirements of government, health care agency, and professional standards of practice.

Question 9

Which actions for electronic health records (EHR) use are universally accepted as good practice?

A) Changing your EHR password frequently.
B) Charting in a quiet location that is free of distractions
C) Sharing passwords only among unit staff involved in client care
D) Save charting until the end of a shift to save time.
E) Log out whenever not actively engaged in charting

Question 10

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

A) It provides a standard language for nursing care.
B) It promotes visibility and defines professional practice of nursing contributions to patient care.
C) It lacks standardized terminologies that promote best practices within nursing.
D) It has not been thoroughly incorporated into many agencies' electronic clinical records.
E) It provides a common language for nursing care.

Question 11

Which statement concerning electronic records in NOT true?

A) They are portable.
B) They are less durable than paper charting.
C) They are easily transferable.
D) They include documents as well as digital images

Question 12

Which is the best definition of the term interoperability?

A) A record system that is fully integrated with the Department of Defense.
B) Access at the point of care or remotely using various digital devices.
C) Disparate systems can "talk to each other" to share patient information.
D) Maintains an exchange of information about the patient among all care providers.

Question 13

"A hierarchical method of classifying a vocabulary of items according to certain rules" is the definition for what term?

A) Health Care Financing Administration (HCFA)
B) Coding
C) NNN
D) Taxonomy