Documentation Flashcards
(20 cards)
a charge nurse is discussing health records with a newly licensed nurse, Which of the following information should the nurse identify as a component of a health record?
- Immunization data
- Record of client health care payments
- Complete medical information for household members
- Facility policies
- Immunization data
a nurse is reviewing documentation principles with a group of newly hired AP. Which of the following information should the nurse include?
Providers designate to other staff which abbreviations cannot be used.
A nurse who delegates a task to an AP will review the charting for that task.
Providers read and cosign nursing documentation for accuracy.
Licensed personnel should document out-of-range vital signs for AP.
A nurse who delegates a task to an AP will review the charting for that task.
a nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on The Joint Commission’s Do Not Use List?
select all that apply
MSO4
IU
PO
qhs
NKA
MSO4
IU
qhs
a nurse is talking with a client about their electronic health record at the facility. Which of the following client statements indicates an understanding of EHRs?
“I will be able to track my health information.”
“My personal information will be entered into a national database.”
“I will have one EHR that will encompass the health care I’ve received over my lifetime.”
“The goal of EHRs is to improve insurance coding.”
“I will be able to track my health information.”
a staff nurse is evaluating a newly licensed nurse’s understanding of telephone Rx’s. Which of the following statements by the newly licensed nurse indicates an understanding of the information?
“I can take a telephone prescription if a provider is making routine rounds in another area of the facility.”
“I can take a telephone prescription if a provider is directing a code for an unresponsive client.”
“If a client requires an over-the-counter medication for relief of nausea, it is okay to accept a telephone prescription.”
“If a client requires pain control for a terminal condition, it is okay to accept a telephone prescription.”
“I can take a telephone prescription if a provider is directing a code for an unresponsive client.”
RATIONALE:
Telephone prescriptions should be reserved for use only in emergency situations, because there is a risk for misunderstanding details about the prescription during verbal communication. An unresponsive client is an emergency, so it is appropriate for a nurse to receive a telephone prescription in this situation.
A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include?
A problem-oriented medical record is created using the PIE model for documentation entries.
A problem-oriented medical record contains separate sections for laboratory and diagnostic information.
A problem-oriented medical record promotes information sharing among members of the interdisciplinary team.
A problem-oriented medical record is rarely used in acute care settings.
A problem-oriented medical record promotes information sharing among members of the interdisciplinary team.
a nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include?
“Accessing the medical record of clients on units other than where you are assigned is allowed.”
“There are large financial penalties for charting vital signs you obtain for another nurse’s client.”
“Personnel can be terminated for breaching a client’s confidentiality.”
“Once you have cared for a client, it is acceptable to look at their medical record on subsequent health care visits.”
“Personnel can be terminated for breaching a client’s confidentiality.”
a nurse is documenting information in a clients chat and makes the entry “client reports abdominal pain of exertion.” which of the following documentation formats describe this entry?
The “I” in PIE
The “S” in SOAP
The “R” in DAR
The “E” in PIE
The “S” in SOAP
a nurse in a client is reviewing a clients prescription prior to discharge. The nurse should instruct the client that which of the following abbreviation indicates the medication can be taken as needed.
PRN
NPO
AC
Ad lib
PRN
a newly licensed nurse is orienting to a facility’s documentation system. The facility requires staff to only document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods?
Charting by exception
Subjective, objective, assessment, plan format
Problem, intervention, evaluation model
Data, action, response charting
Charting by exception
RATIONALE:
With charting by exception (CBE), health care professionals only chart unexpected findings. This can be done on a flowsheet or through narrative notes.
A nurse is discussing the history of EHR during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs?
The Institute of Medicine
Department of Veteran Affairs
American Hospital Association
The Joint Commission
The Institute of Medicine
RATIONALE:
The nurse should identify that the Institute of Medicine is the agency that recommended nationwide use of EHRs in 1997. The recommendation was driven by the belief that it would increase safety in client health care.
a charge nurse is reviewing characteristics of electronic documentation with stagg at a providers office. Which of the following characteristics should the charge nurse plan to include? select all that apply
Reduces medical errors
Improves listening skills among interdisciplinary team members
Less convenient than paper-based charting
Makes client medical history more easily available
Increases accuracy of coding procedures
Reduces medical errors
Makes client medical history more easily available
Increases accuracy of coding procedures
a nurse is assisting with the care of a client following a stroke. The nurse should recognize that which of the following individuals is allowed access to the client’s medical record without obtaining special consent from the client first? select all that apply
The admitting provider
The charge nurse on the unit
The client’s sibling
The client
The client’s spiritual advisor
The admitting provider
The charge nurse on the unit
The client
a nurse is discussing computerized provider order entry systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE.
“CPOE systems are associated with a slightly higher error rate.”
“CPOE use does not include medication prescriptions.”
“CPOE systems can increase the speed of care delivery.”
“CPOE use is mandated by HIPAA under the Privacy Rule.”
“CPOE systems can increase the speed of care delivery.”
a nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following information should the nurse include as a benefit of electronic documentation?
The system alerts providers of possible actions that could cause client harm.
An electronic system prevents breaches of confidentiality of client data.
Providers can document client information in the electronic record during system downtime.
System encryption eliminates the need for security firewalls.
The system alerts providers of possible actions that could cause client harm.
a nurse is preparing to administer morphine 15mg PO q4hrs PRN pain for a client who has a new RX. By which of the following routes should the nurse plan to administer the medication?
By mouth
Intramuscularly
Per rectum
Intravenously
By mouth
a nurse is discussing legal regulations regarding medical records with a newly hired AP. Which of the following information should the nurse include?
American Nurse Association (ANA) standards prevent client records from being used for legal proceedings.
HIPAA regulations vary from one state to another.
Privacy regulations apply to electronic data transfer rather than verbal communication.
Facilities can establish their own rules for documentation methods.
Facilities can establish their own rules for documentation methods.
a nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries should the nurse identify as meeting the ANA standards for documentation?
“The client is now asleep, and they ate most of their breakfast a few hours ago.”
“The client vomited 240 mL of clear emesis but denies pain or nausea.”
“The client reports not feeling good, but they look fine.”
“The client has 8 to 10 sores on their body.”
“The client vomited 240 mL of clear emesis but denies pain or nausea.”
a nurse manager is reviewing the documentation of four newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly?
Synthroid 100 mcg PO every morning ac
Enoxaparin 75 mg SQ bid
Digoxin 0.25 mg PO qd
Metformin 500.0 mg PO with evening meal
Synthroid 100 mcg PO every morning ac
a charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data?
The client states, “I’ve had abdominal pain for the past 3 days.”
The client reports consuming about 1,500 mL of water per day.
Rebound tenderness noted in RLQ of the abdomen.
Recommend client referral to a registered dietitian.
Rebound tenderness noted in RLQ of the abdomen.
