Documentation, Electronic health records, and Reporting (Chap 10)

Question 1

Any written or electronically generated information about a patient that describes the patient, the patient’s health, and the care and services provided, including the dates of care.

Answer 1

Healthcare documentation

Question 2

A document with comprehensive info about a patient’s healthcare encounter, as well as demographic, administrative, and clinical data. Legal document.

Answer 2

Medical record

Question 3

A record of one record of care such as inpatient stay or an outpatient appt.

Answer 3

Electronic medical record (EMR)

Question 4

A longitudinal record of health that includes the information from inpatient and outpatient episodes of healthcare from one or more care settings.

Answer 4

Electronic health record (EHR)

Question 5

Major components of this record includes health information, diagnostic test results, order-entry system, and decision support.

Answer 5

Electronic health record (EHR)

Question 6

This allows clinicians to enter orders in a computer that are sent to appropriate department.

Answer 6

Computerized provider order entry (CPOE)

Question 7

Documentation of any record should be:
FANP

Answer 7

Factual, Accurate, Nonjudgmental, and Proper Grammar.

Question 8

What are the 5 steps of the nursing process? ADPIE

Answer 8

Assessment, Diagnosis, Planning, Implementation, and Evaluation

Question 9

What abbreviations should you NOT use?

Answer 9

U unit
IU international unit
QD daily
QOD every other day
MS morphine sulfate
MSO4 morphine sulfate
MgSO4 magnesium sulfate

Question 10

This record integrates charting from the entire healthcare team in the same section of the record. Problem-oriented structure.

Answer 10

Problem-oriented medical record (POMR)

Question 11

PIE

Answer 11

Problem, Intervention, Evaluation

Question 12

APIE

Answer 12

Assessment, Problem, Intervention, Evaluation

Question 13

SOAP

Answer 13

Subjective data, Objective date, Assessment, Plan

Question 14

SOAPIE

Answer 14

Subjective data, Objective data, Assessment, Plan, Intervention, Evaluation

Question 15

SOAPIER

Answer 15

Subjective data, Objective data, Assessment, Plan, Intervention, Evaluation, Revisions to plan.

Question 16

DAR (used to chart data)

Answer 16

Data, Action, Response

Question 17

CBE (documentation that records only abnormal or significant data)

Answer 17

Charting by exception

Question 18

A list of ordered medications, along with dosages, routes, and times of administration.

Answer 18

Medication administration record (MAR)

Question 19

A portable scanner is used and the nurse scans the patient’s wristband and the medication to be given.

Answer 19

Bar-coded medication administration (BCMA)

Question 20

The real time process of passing patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety.

Answer 20

Hands-off reports

Question 21

A safety occurrence that affects a patient and causes death, serious permanent or temporary injury, or requires interventions to sustain life.

Answer 21

A sentinel event

Question 22

SBAR a communication format specifically suggested for use in nurse-physician interactions.

Answer 22

Situation, Background, Assessment of the problem, Recommendation for a solution

Question 23

ISBAR

Answer 23

Identification of healthcare providers involved in hand-off, Situation, Background, Assessment of problem, Recommendation for a solution.