Deck 74: Documentation and Informatics

Question 1

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

A) Appears restless when sitting in the chair
B) Drank adequate amounts of water
C) Apparently is asleep with eyes closed
D) Skin pale and cool

Answer 1

D
A factual record contains descriptive,objective information about what a nurse sees,hears,feels,and smells.An objective description is the result of direct observation and measurement.For example,"B/P 80/50,patient diaphoretic,heart rate 102 and regular." Avoid vague terms such as appears,seems,or apparently because these words suggest that you are stating an opinion,do not accurately communicate facts,and do not inform another caregiver of details regarding behaviors exhibited by the patient.Use of exact measurements establishes accuracy.For example,a description such as "Intake,360 mL of water" is more accurate than "Patient drank an adequate amount of fluid."

Question 2

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?

A) Electronic medical record
B) Electronic health record
C) Electronic charting record
D) Electronic problem record

Answer 2

B
A unique feature of an electronic health record (EHR)is its ability to integrate all pertinent patient information into one record,regardless of the number of times a patient enters a health care system.Although the electronic medical record (EMR)contains patient data gathered in a health care setting at a specific time and place and is a part of the EHR,the two terms are frequently used interchangeably.There are no such terms as electronic charting record or electronic problem record.

Question 3

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

A) Acuity level
B) Community resources
C) Standardized care plan
D) Kardex

Answer 3

B
Discharge documentation includes medications,diet,community resources,follow-up care,and whom to contact in case of an emergency or for questions.A patient's acuity level,usually determined by a computer program,is based on the type and number of nursing interventions (e.g.,intravenous [IV] therapy,wound care,ambulation assistance)required over a 24-hour period.Acuity level can be used for staffing and billing.Some institutions use standardized care plans to make documentation more efficient.The plans,based on the institution's standards of nursing practice,are preprinted,established guidelines used to care for patients who have similar health problems.In some settings,a Kardex,a portable "flip-over" file or notebook,is kept at the nurses' station.Most Kardex forms have an activity and treatment section and a nursing care plan section,which organize information for quick reference.

Question 4

A nurse has provided care to a patient.Which entry should the nurse document in the patient's record?

A) "Patient seems to be in pain and states, 'I feel uncomfortable.'"
B) Status unchanged, doing well
C) Left abdominal incision 1 inch in length without redness, drainage, or edema
D) Patient is hard to care for and refuses all treatments and medications. Family present.

Question 5

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

A) Database
B) Medical history and examination
C) Progress notes
D) Graphic sheet and flow sheet

Question 6

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

A) Kardex form
B) Admission nursing history
C) Mode of transportation
D) SOAP notes

Question 7

Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients' health records?

A) The nurse determines the degree to which standards of care are met by reviewing patients' health records.
B) The nurse realizes that care not documented in patients' health records still qualifies as care provided.
C) The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records.
D) The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment.

Question 8

Which situation will require the nurse to obtain a telephone order?

A) As the nurse and primary care provider leave a patient's room, the primary care provider gives the nurse an order.
B) At 0100, a patient's blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood.
C) At 0800, the nurse and primary care provider make rounds and the primary care provider tells the nurse a diet order.
D) A nurse reads an order correctly as written by the primary care provider in the patient's medical record.

Question 9

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough.When is the best time the nurse should start discharge planning for this patient?

A) Upon admission
B) Right before discharge
C) After the congestion is treated
D) When the primary care provider writes the order

Question 10

A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart.What is the preceptor's best response?

A) "A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care."
B) "A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs."
C) "A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities."
D) "A change-of-shift report provides important information to caregivers and develops relationships within the health care team."

Question 11

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) Nursing process form
B) Step-by-step skills manual
C) A list of possible procedures
D) Reports to third party payers

Question 12

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) Patient went up and down stairs
B) Deficient knowledge regarding crutches
C) Demonstrated use of crutches
D) Used crutches with no difficulties

Question 13

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

A) The new nurse uses a black ink pen to chart.
B) The new nurse charts consecutively on every other line.
C) The new nurse ends each entry with signature and title.
D) The new nurse keeps the password secure.

Question 14

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) Pupils equal and reactive to light
B) The family is a "pain"
C) Had poor results from the pain medication
D) Sharp pain of 8 on a scale of 1 to 10

Question 15

A nurse prepared an audiotaped exchange with another nurse of information about a patient.Which action did the nurse complete? The nurse completed a

A) Report.
B) Record.
C) Consultation.
D) Referral.

Question 16

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

A) The student nurse reviews the patient's medical record.
B) The student nurse reads the patient's plan of care.
C) The student nurse shares patient information with a friend.
D) The student nurse documents medication administered to the patient.

Question 17

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

A) Charts legibly
B) States the patient is belligerent
C) Uses correction fluid to correct error
D) Writes entry for another nurse

Question 18

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) Focus charting using the DAR format.
B) Add this data to the problem list.
C) Document the variance in the patient's record.
D) Report a positive variance in the next interdisciplinary team meeting.

Question 19

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

A) The patient had a good day with no complaints.
B) The family is demanding and argumentative.
C) The patient has a new pain medication, Lortab.
D) The family is poor and had to go on welfare.

Question 20

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning and for meeting quality improvement within and across facilities.Which task did the nurse just complete?

A) A focused assessment/specific body system
B) The Resident Assessment Instrument/Minimum Data Set
C) An admission assessment and acuity level
D) An intake assessment form and auditing phase

Question 21

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

Question 22

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 Tylenol 3, 2 tablets, every 6 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.
B) 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN, read back.
C) 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.
D) 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN.

Question 23

A nurse is discussing the advantages of standardized documentation forms in the nursing 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

Question 24

A nurse has taught the staff about informatics.Which statement indicates that the staff needs more education?

A) If a nurse has computer competency, the nurse is competent in informatics.
B) To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice.
C) A nurse needs to know how to acquire, critique, and apply scientific evidence from literature databases.
D) Nursing informatics integrates nursing science, computer science, and information science to manage and communicate information in nursing practice.

Question 25

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 ox 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.

Question 26

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

A) Sentinel events help determine reimbursement issues for health care.
B) Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care.
C) A clinical information system must be installed by 2014 to obtain health care reimbursement.
D) HIPAA is the basis for establishing reimbursement for health care.

Question 27

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

A) Create a password with just letters.
B) Bypass the firewall.
C) Use a programmed speed-dial key when faxing.
D) Implement an automatic sign-off.
E) Impose disciplinary actions for inappropriate access.
F) Shred papers containing personal health information (PHI).

Question 28

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

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.

Question 29

Identify the purposes of a health care record.

A) Communication
B) Legal documentation
C) Reimbursement
D) Education
E) Research
F) Nursing process

Question 30

Which behaviors indicate that the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)?

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) Reads the progress notes of assigned patient's record
E) Gives a change-of-shift report to the oncoming nurse about the patient
F) Discusses patient care with the hospital volunteer

Question 31

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

A) 0800
B) 0810
C) 0815
D) 0830