Chapter 26- Informatics and Documentation

sharing patient information with another student

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

a verbal report

A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete?

Determining degree to which standards of care are met by reviewing patients health records

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking?

Skin is pale and cool

After providing care, a nurse charts the patient record. Which entry will the nurse document?

Left knee incision 1 inch in length without redness, drainage, or edema

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

Charts consecutively on every other line

Which action by the novice nurse will cause the preceptor to provide follow up instructions?

Charts in a legible manner

Which action by the nurse take legally when charting on a patient's record?

electronic health record

A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse access?

demonstrated use of crutches

A nurse has instructed the patient regarding the proper use of 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?

graphic record and flow sheet

A nurse wants to find the daily weights of a hospitalized patient. Which resource will the nurse consult?

Document the variance in the patient's record

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?

upon admission

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

community resources

a patient has been discharged home. Which information should the nurse include?

Mode of transportation

A nurse developed the following discharge summary sheet. What critical information should the nurse add?

Reports to third-party payers

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 minimum data set

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which tasks is the nurse completing?

the patient received a pain medication

A nurse is charting. Which event is critical for the nurse to document?

Home Health

A nurse is completing an Outcome and Assessment Information Set (OASIS) data set on a

patient. The nurse works in which area of patient care?

Reports sharp pain of 8 on a scale of 1 to 10.

A nurse is preparing to document a patient who has reported chest pain. Which information

provided by the patient is critical for the nurse to include?

Read back the order as written to the health care provider for verification.

Which action will the nurse take when taking a telephone order?

12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr.

Day/J. Winds, RN, read back.

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which

chart entry should the nurse document

If a nurse has computer competency, the nurse is competent in informatics

A nurse is teaching the staff about informatics. Which information from the staff indicates the

nurse needs to follow up?

Critical pathway design

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?

Chart on the computer immediately after care is provided.

A nurse wants to reduce data entry errors on the computer system. Which action should the

nurse take?

0830

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

0800 Patient states, ―Fell out of bed.‖ Patient found lying by bed on the floor. Legs equal in

length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no

bruising or bleeding. Neuro checks within normal limits. States, ―Did not pass out.‖ Assisted

back to bed. Nurse call system within reach. Bed monitor on. —Jane More, RN

0810 Notified primary care provider of patient's status. New orders received. —Jane More,

RN

0815 Portable x-ray of L hip taken in room. States, ―I feel fine.‖ —Jane More, RN

0830 Incident report completed and placed on chart. —Jane More, RN

Used incentive spirometer to encourage coughing and deep breathing. Lung

congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%.

Oxygen per nasal cannula applied at 2 L/min per standing order.

A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with

financial reimbursement?

Home health, long-term care, and hospital nurses' documentation can affect

reimbursement for health care.

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

nurse include in the teaching session?

b. Reduced errors of omission

A nurse is discussing the advantages of a nursing clinical information system. Which

advantage should the nurse describe?

Gives a change-of-shift report to the oncoming nurse about the patient.

Reads the progress notes of assigned patient's record.

Which behaviors indicate the student nurse has a good understanding of confidentiality and

the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)

Communication

Legal documentation

Reimbursement

Research

Education

A nurse is describing the purposes of a health care record to a group of nursing students.

Which purposes will the nurse include in the teaching session? (Select all that apply.)

Implement an automatic sign-off.

Use a programmed speed-dial key when faxing.

Impose disciplinary actions for inappropriate access.

Shred papers containing personal health information (PHI).

A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which

guidelines should the nurse include? (Select all that apply.)

Patient states, ―can't catch my breath and chest hurts.‖ Confused.

A nurse is using focused charting referred to as DAR. Match the chart entry to the correct

letter of the acronym. D

Applied oxygen, stayed with patient, and instructed to slow breathing.

A nurse is using focused charting referred to as DAR. Match the chart entry to the correct

letter of the acronym. A

Patient states, ―feel better,‖ respirations 16 with O2 saturations 96%.

A nurse is using focused charting referred to as DAR. Match the chart entry to the correct

letter of the acronym. R

"Read back" all telephone orders to the health care provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the EHR.

A nurse contacts the health care provider about a change in a patient's condition and receives several new orders for the patient over the phone. When documenting telephone orders in the EHR, what should the nurse do?

-Using a strong password and changing your password frequently according to agency policy

-Ensuring that work lists (and any other data that must be printed from the EHR) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed

-Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care

You are a nurse who is working in an agency that has recently implemented an EHR. Which of the following are acceptable practices for maintaining the security and confidentiality of EHR information? (Select all that apply.)

Charting by exception (CBE)

When documenting an assessment of a patient's cardiac system in an EHR, the nurse uses the computer mouse to select the "WNL" statement to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80 and 100 beats/min, and regular. Denies chest pain." This is an example of using which of the following documentation formats?

0005

The nurse works at an agency where military time is used for documentation and needs to document that a patient was medicated for pain after midnight. Identify the correct military time to document medication administered at 12:05 a.m.

-Confirm that the fax number for the acute rehabilitation center is correct before sending the fax.

-Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key.

-After sending the fax, place the information that was printed out in a secure canister marked for shredding.

The nurse who works at the local health care agency is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient's EHR must be printed and faxed to the acute rehabilitation center. Which of the following actions are appropriate for the nurse to take to maintain privacy and confidentiality of the patient's information when faxing this information? (Select all that apply.)

Clinical decision support system (CDSS)

The nurse is administering a dose of metoprolol to a patient and is completing the steps of bar-code medication administration within the EHR. As the bar-code information on the medication is scanned, an alert that states, "Do not administer dose if apical heart rate (HR) is <60 beats/min or systolic blood pressure (SBP) is <90 mm Hg" appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system?

CPOE improves patient safety by reducing transcription errors.

The nurse is discussing the advantages of using CPOE with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an EHR?

Insulin aspart 8u SQ every morning before breakfast

The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contains an inappropriate abbreviation included on TJC's "do not use" list and should be clarified with the health care provider?

09-3-21 (1015): Surgeon contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN

The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation?