NR 224 Documentation and Informatics

What are the benefits of using an electronic health record (EHR) for the health professional? Select all that apply.​

1. Ability to document clinical reasoning

2. Remote access

3. Continuity of care

4. All data is readily accessible

5. Access to records anytime

A longitudinal record of an individual’s interactions with the healthcare system.

Electronic Health Record (EHR)

The legal record documenting a single encounter between an individual and a healthcare professional.

Electronic Medical Record (EMR)

What are the advantages to clients that are realized by using an electronic health record (EHR)? Select all that apply.

1. Increased safety

2. Continuity of care

After a year of planning and saving, Davon (preferred pronouns: she, her) and her partner are taking a well-deserved beach vacation. During their bicycle tour, one of the other sight-seers stops suddenly, causing Davon to swerve and crash. Despite wearing a helmet, Davon loses consciousness. When paramedics arrive, they ask Davon’s partner about her health history. What is the best way to provide this information? 

Electronically by Davon’s partner accessing a copy of her EHR

By the time Davon arrives at the emergency department, she has regained consciousness and requests that her healthcare provider send a copy of her health record to the ED via fax. Instead of arriving in the ED, the fax was received on the machine in the business office. The cover sheet identifies the name and phone number of the intended recipient, the name, fax, and phone number of the sender, which are all correct. Unfortunately, two digits in the fax number were typed incorrectly.

How could this breach of confidentiality have been prevented?​ Select all that apply.

1. Compare the number dialed to the confirmed number on the fax cover sheet before hitting the send button.

2. Confirm the fax number is correct before sending

Two hours into the shift, the current nurse receives a call from the colleague who cared for Mr. Hilliard the previous shift. The colleague shares that they forgot to document a call to Mr. Hilliard’s healthcare provider about a potential surgical wound infection and asks the current nurse to document that information.

What is the best response by the current nurse?

“You’ll be back tonight, just add it as a late entry”