PD1: Use of E-Documentation in Health Information Technology Systems Sherpath

Which informatics skill would be required by the QSEN competencies for new graduate nurses?

Select all that apply. One, some, or all responses may be correct.

Data entry

Spreadsheet entry

Use of social media

Data transmission

Word processing

Data entry

Correct answer

Nurses are expected to have competency in accurate data entry in order to maintain accurate and clear patient records.

Spreadsheet entry

Correct answer

QSEN recommends ability to enter data into spreadsheets as an essential competency.

Data transmission

Correct answer

Nurses require skill in data transmission to safely enter and communicate patient information.

Word processing

Correct answer

According to QSEN recommendation, nurses must have skill in word processing to enter patient information.

In which situation would the nurse question a written order?

When the physician orders a medication different than what the patient requested

When the physician orders a medication dosage larger than the standard dose

When the physician orders three medications at the same time

When the physician orders continual IV fluid administration

When the physician orders a medication dosage larger than the standard dose

Correct answer

A medication dosage that seems too large for the patient or standard in the situation would potentially be unsafe and should be questioned by the nurse.

Which concern would arise from the creation of work-arounds by nurses?

The nurse may change the functioning of the EHR program causing an error.

The nurse may accidentally share patient information with others not caring for the patient.

The nurse may bypass a system that is in place for patient safety.

The nurse may enter additional medications that were not ordered into the EHR.

The nurse may bypass a system that is in place for patient safety.

Correct answer

The nurse who creates a work-around may bypass a system designed to improve patient safety in the process of creating the work-around and make care less safe.

Which action by the nurse would reduce the safety of the electronic health record (EHR)?

Resetting their EHR password every 30 days

Charting a neurologic exam at the time a change in status is observed

Attending a training event on use of a new clinical support tool in the EHR

Copying physical assessment documentation from the previous shift for reuse

Copying physical assessment documentation from the previous shift for reuse

Correct answer

Cutting and pasting data is a common work-around of nurses to save time. This can reduce the safety of the EHR as it predisposes documentation to inaccuracies and the potential for mis-documentation of small changes in patient status.

Which step would be taken by the nurse to avoid data entry errors?

Select all that apply. One, some, or all responses may be correct.

Log on and off the EHR system properly.

Document at the end of the shift.

Avoid charting in the wrong patient record.

Prevent use of nonstandard terminology.

Ask the family to verify patient data.

Log on and off the EHR system properly.

Correct answer

Logging on and off the system properly ensures security and reduces risk for documentation errors.

Avoid charting in the wrong patient record.

Correct answer

Nurses should be cautious to verify they are inputting data into the correct patient record each time.

Prevent use of nonstandard terminology.

Correct answer

Nonstandard terminology should be avoided. Use of commonly accepted standard terms should be used to make documentation clear.

Which classification system would the nurse use to code for intramuscular injection of a therapeutic substance?

ICD-10

SNOMED-CT

ICD-10-PCS

DSM-5

ICD-10-PCS

Correct answer

ICD-10-PCS is used to code for medical procedures performed.

Which recommendation would the nurse make to the information technology (IT) developer to reduce the incidence of data processing errors?

Remove highly specific documentation choices in the EHR

Require documentation input within 30 minutes of event occurrence

Use only free-text entry options in documentation

Interface with personal patient health-tracking applications to add data

Remove highly specific documentation choices in the EHR

Correct answer

Overly specific documentation choices in the EHR created by programmers can make it difficult to capture the complexity of nursing care and cause documentation error.

In which situation would a verbal order be most appropriate?

When the physician is in a hurry to leave the hospital unit

When a change in a patient’s condition requires the nurse to phone a physician

When the patient becomes impatient while waiting for the physician to enter a medication order

When the physician orders a new medication

When a change in a patient’s condition requires the nurse to phone a physician

Correct answer

A change in patient’s health condition requires an urgent response from a physician. In such a situation, the nurse may have to take and enter a verbal order.

Which nurse action exemplifies an unsafe workaround intended to reduce the workload in the electronic health record (EHR)?

Entering multiple sets of vital signs at the same time

Manually documenting a medication rather than scanning the barcode

Documenting specific patient comments in the record

Selecting documentation from a list of preset choices

Manually documenting a medication rather than scanning the barcode

Correct answer

Manual entry of medication administration bypasses the safety systems put in place in EHRs using barcode scanning systems. These systems verify patient and medication to reduce administration errors.

Which action would improve the efficiency of nursing documentation?

Select all that apply. One, some, or all responses may be correct.

Allowing autocorrect in the software to proofread and fix errors in narrative documentation

Sharing the EHR password to allow a nursing colleague to assist with documentation

Avoiding the use of abbreviations in documentation

Repeating information from documentation checklists in the free text portion of the EHR

Double-checking numeric data when it is entered for any transpositions of numbers

Allowing autocorrect in the software to proofread and fix errors in narrative documentation

Correct answer

Using autocorrect and/or proofreading tools in the EHR can help to find and correct errors in nursing documentation for the nurse. Doing so improves efficiency and reduces time spent proofreading and correcting documentation.

Avoiding the use of abbreviations in documentation

Correct answer

Abbreviations can be ambiguous and cause confusion in some situations, which makes review of the EHR less efficient and could change the meaning of documentation or lead to errors in orders. Therefore, abbreviations should be avoided.

Double-checking numeric data when it is entered for any transpositions of numbers

Correct answer

Checking any numeric data in charting ensures that transpositions of numbers did not occur which would produce an inaccuracy of the record and make documentation less useful. This may also create incorrect calculation that require revision later, which is not efficient.

Which method would the nurse use to make charting at the bedside more comfortable for the patient?

Avoid documenting at the bedside.

Turn the computer so the nurse can look at the patient while documenting.

Entering data rapidly to avoid spending large amounts of time on the computer.

Ask the patient to participate in documenting the record.

Turn the computer so the nurse can look at the patient while documenting.

Correct answer

Positioning the computer terminal so the nurse can face the patient and talk with the patient while charting gives warmth.

Which outcome would be a goal of developing standardized terminology and classification codes for nursing care?

Making nursing practice visible in the electronic health record (EHR)

Saving time in nursing documentation

Providing new ways to communicate nursing care

Changing the EHR functions to make documentation easier

Making nursing practice visible in the electronic health record (EHR)

Correct answer

The goal of developing standardized terminology is to help make nursing practice clear and visible in computerized health systems to demonstrate the work completed and complexity of care provided.