Deck 25: Documentation in an Electronic Era

Question 1

Which of the following is a disadvantage of computerized charting?

A) Ability to aggregate data
B) Improved access to health record
C) Standardized charting
D) Preset activities that can be coded

Answer 1

Standardized charting

Question 2

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

A) Omaha system of client problems
B) Clinical pathways
C) Nursing intervention classification
D) International classification of disease (ICD)

Answer 2

Nursing intervention classification

Question 3

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

A) record complete, pertinent health information.
B) write about the incident report in the client record.
C) store the incident report in the client record.
D) make untimely entries.

Answer 3

record complete, pertinent health information.

Question 4

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?

A) Nursing outcomes classification (NOC)
B) Diagnostic-related groups
C) Nursing intervention classification
D) North American Nursing Diagnosis (NANDA)

Question 5

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

A) Every nurse should anticipate having clients' 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.

Question 6

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 client 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 7

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?

A) North American Nursing Diagnosis (NANDA)
B) Nursing intervention classification
C) Nursing outcome classification
D) Omaha system of client problems

Question 8

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

A) NANDA
B) NIC
C) NOC
D) Omaha system

Question 9

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

A) Recording on the wrong chart
B) Failure to document an intervention
C) Failure to document a discontinued medication
D) Failure to record outcome of an intervention

Question 10

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

A) It communicates to others whether or not care was received.
B) It conveys pertinent information about the client's condition and response to treatment interventions.
C) It substantiates the quality of care by showing adherence to care standards.
D) It provides evidence for reimbursement.
E) It serves as a source of data that can be compiled or aggregated and then analyzed to establish "best practice" interventions.
F) It is not a source for communicating care to others due to HIPAA rules and regulations.

Question 11

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

A) narration.
B) documentation.
C) care coordination.
D) order entry.

Question 12

All of the following are true about electronic records except

A) they are portable.
B) they are less durable than paper charting.
C) they are easily transferable.
D) they are more durable than paper charting.

Question 13

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

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

Question 14

One major advantage of an electronic health information technology system is

A) lack of integration.
B) accessibility of health records.
C) it is not easily transferable.
D) it consists of imaging files that allow for delayed access.