Chapter 26: Documentation and Informatics Nursing School Test Banks

Test Bank

MULTIPLE CHOICE

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

a.

The student nurse reviews the patients medical record.

b.

The student nurse reads the patients plan of care.

c.

The student nurse shares patient information with a friend.

d.

The student nurse documents medication administered to the patient.

ANS: C

When you are a student in a clinical setting, confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares patient information with a friend, confidentiality and HIPAA standards have been violated. You can review your patients medical records only to seek information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patients medical record and plan of care. You do not share this information with classmates and you do not access the medical records of other patients on the unit.

DIF: Apply REF: 349

OBJ: Identify ways to maintain confidentiality of electronic and written records.

TOP: Evaluation MSC: Management of Care

2. A nurse prepared an audiotaped exchange with another nurse of information about a patient. Which action did the nurse complete? The nurse completed a

a.

Report.

b.

Record.

c.

Consultation.

d.

Referral.

ANS: A

Reports are oral, written, or audiotaped exchanges of information among caregivers. A patients record or chart is a confidential, permanent legal document consisting of information relevant to his or her health care. Consultations are another form of discussion in which one professional caregiver gives formal advice about the care of a patient to another caregiver. Nurses document referrals (arrangements for the services of another care provider).

DIF: Remember REF: 349

OBJ: Describe interdisciplinary communication within the health care team.

TOP: Implementation MSC: Communication and Documentation

3. Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients health records?

a.

The nurse determines the degree to which standards of care are met by reviewing patients health records.

b.

The nurse realizes that care not documented in patients health records still qualifies as care provided.

c.

The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients records.

d.

The nurse compares data in patients records to determine whether a new treatment had better outcomes than the standard treatment.

ANS: A

The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing/monitoring. The auditing/monitoring purpose involves nurses auditing records throughout the year to determine the degree to which standards of care are met and to identify areas needing improvement and staff development. The legal documentation purpose involves the concept that even though nursing care may have been excellent, in a court of law, care not documented is care not provided. The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patients recorded findings to determine whether the new method was more effective than the standard protocol. Analysis of data from research contributes to evidence-based nursing practice and quality health care.

DIF: Analyze REF: 350 OBJ: Identify the purposes of a health care record.

TOP: Evaluation MSC: Communication and Documentation

4. After providing care, a nurse charts in the patients record. Which entry should the nurse document?

a.

Appears restless when sitting in the chair

b.

Drank adequate amounts of water

c.

Apparently is asleep with eyes closed

d.

Skin pale and cool

ANS: D

A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. An objective description is the result of direct observation and measurement. For example, B/P 80/50, patient diaphoretic, heart rate 102 and regular. Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the patient. Use of exact measurements establishes accuracy. For example, a description such as Intake, 360 mL of water is more accurate than Patient drank an adequate amount of fluid.

DIF: Apply REF: 350

OBJ: Describe five quality guidelines for documentation and reporting.

TOP: Evaluation MSC: Communication and Documentation

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

a.

Patient seems to be in pain and states, I feel uncomfortable.

b.

Status unchanged, doing well

c.

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

d.

Patient is hard to care for and refuses all treatments and medications. Family present.

ANS: C

Use of exact measurements establishes accuracy. Charting that an abdominal wound is 5 cm in length without redness, drainage, or edema is more descriptive than large wound healing well. Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as status unchanged or had a good day. It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions. Patient is hard to care for is a personal opinion and should be avoided. It is also a critical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, Refuses all treatments and medications.

DIF: Apply REF: 350-351

OBJ: Describe five quality guidelines for documentation and reporting.

TOP: Evaluation MSC: Communication and Documentation

6. A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to intervene?

a.

The new nurse uses a black ink pen to chart.

b.

The new nurse charts consecutively on every other line.

c.

The new nurse ends each entry with signature and title.

d.

The new nurse keeps the password secure.

ANS: B

Chart consecutively, line by line (not every other line); if space is left, draw a line horizontally through it, and sign your name at the end. Every other line should not be left blank. Record all entries legibly and in black ink. End each entry with your signature and title. For computer documentation, keep your password to yourself. Using black ink, ending each entry with signature and title, and keeping the password secure are all appropriate behaviors.

DIF: Apply REF: 351 OBJ: Discuss legal guidelines for documentation.

TOP: Evaluation MSC: Management of Care

7. A nurse is charting on a patients record. Which action is most accurate legally?

a.

Charts legibly

b.

States the patient is belligerent

c.

Uses correction fluid to correct error

d.

Writes entry for another nurse

ANS: A

Record all entries legibly. Do not write personal opinions. Enter only objective and factual observations of patients behavior; quote all patient comments. For example, patient refuses to cough and deep breathe, saying, I dont care what you say, I will not do it. Do not erase, apply correction fluid, or scratch out errors made while recording. Chart only for yourself.

DIF: Understand REF: 351 OBJ: Discuss legal guidelines for documentation.

TOP: Planning MSC: Communication and Documentation

8. A nurse wants to integrate all pertinent patient information into one record, regardless of the number of times a patient enters the health care system. Which term should the nurse use to describe this system?

a.

Electronic medical record

b.

Electronic health record

c.

Electronic charting record

d.

Electronic problem record

ANS: B

A unique feature of an electronic health record (EHR) is its ability to integrate all pertinent patient information into one record, regardless of the number of times a patient enters a health care system. Although the electronic medical record (EMR) contains patient data gathered in a health care setting at a specific time and place and is a part of the EHR, the two terms are frequently used interchangeably. There are no such terms as electronic charting record or electronic problem record.

DIF: Understand REF: 353

OBJ: Describe the different methods used in record keeping. TOP: Diagnosis

MSC: Communication and Documentation

9. A nurse has taught the patient how to use 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?

a.

Patient went up and down stairs

b.

Deficient knowledge regarding crutches

c.

Demonstrated use of crutches

d.

Used crutches with no difficulties

ANS: C

A second progress note method is the PIE format. The narrative note includes PProblem, IIntervention, and EEvaluation. The intervention is Demonstrated use of crutches. Patient went up and down stairs and Used crutches with no difficulties are examples of the E. Deficient knowledge regarding crutches is the P.

DIF: Apply REF: 354

OBJ: Describe the different methods used in record keeping. TOP: Implementation

MSC: Communication and Documentation

10. A nurse is using the source record and wants to find the daily weights. Where should the nurse look?

a.

Database

b.

Medical history and examination

c.

Progress notes

d.

Graphic sheet and flow sheet

ANS: D

In a source record, the patients chart has a separate section for each discipline (e.g., nursing, medicine, social work, respiratory therapy) in which to record data. Graphic sheets and flow sheets are records of repeated observations and measurements such as vital signs, daily weights, and intake and output. In the problem-oriented medical record, the database section contains all available assessment information pertaining to the patient (e.g., history and physical examination, the nurses admission history and ongoing assessment, the dietitians assessment, laboratory reports, radiologic test results). In the source record, the medical history and examination contain results of the initial examination performed by the physician, including findings, family history, confirmed diagnoses, and medical plan of care. In the source record, the progress notes contain an ongoing record of the patients progress and response to medical therapy and a review of the disease process; it often is interdisciplinary and includes documentation from health-related disciplines (e.g., health care providers, physical therapy, social work).

DIF: Apply REF: 353-355

OBJ: Describe the different methods used in record keeping. TOP: Planning

MSC: Communication and Documentation

11. 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?

a.

Focus charting using the DAR format.

b.

Add this data to the problem list.

c.

Document the variance in the patients record.

d.

Report a positive variance in the next interdisciplinary team meeting.

ANS: C

A variance occurs when the activities on the critical pathway are not completed as predicted, or the patient does not meet expected outcomes. An example of a variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a patient progresses more rapidly than expected (e.g., use of a Foley catheter may be discontinued a day early). When a nurse is using the problem-oriented medical record, after analyzing data, health care team members identify problems and make a single problem list. A type of narrative format charting is focus charting. It involves the use of DAR notes, which include DData (both subjective and objective), AAction or nursing intervention, and RResponse of the patient (i.e., evaluation of effectiveness).

DIF: Apply REF: 354-355

OBJ: Describe interdisciplinary communication within the health care team.

TOP: Implementation MSC: Communication and Documentation

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

a.

Upon admission

b.

Right before discharge

c.

After the congestion is treated

d.

When the primary care provider writes the order

ANS: A

Ideally, discharge planning begins at admission. Right before discharge is too late for discharge planning. After the congestion is treated is also too late for discharge planning. Usually the primary care provider writes the order too close to discharge, and nurses do not need an order to begin the teaching that will be needed for discharge. By identifying discharge needs early, nursing and other health care professionals can begin planning for home care, support services, and any equipment needs at home.

DIF: Apply REF: 356

OBJ: Identify elements to include when documenting a patients discharge plan.

TOP: Planning MSC: Communication and Documentation

13. A patient is being discharged home. Which information should the nurse include?

a.

Acuity level

b.

Community resources

c.

Standardized care plan

d.

Kardex

ANS: B

Discharge documentation includes medications, diet, community resources, follow-up care, and whom to contact in case of an emergency or for questions. A patients acuity level, usually determined by a computer program, is based on the type and number of nursing interventions (e.g., intravenous [IV] therapy, wound care, ambulation assistance) required over a 24-hour period. Acuity level can be used for staffing and billing. Some institutions use standardized care plans to make documentation more efficient. The plans, based on the institutions standards of nursing practice, are preprinted, established guidelines used to care for patients who have similar health problems. In some settings, a Kardex, a portable flip-over file or notebook, is kept at the nurses station. Most Kardex forms have an activity and treatment section and a nursing care plan section, which organize information for quick reference.

DIF: Apply REF: 356

OBJ: Identify elements to include when documenting a patients discharge plan.

TOP: Planning MSC: Communication and Documentation

14. A nurse developed the following discharge summary sheet. Which critical information should be added?

TOPIC

DISCHARGE SUMMARY

Medication

Diet

Activity level

Follow-up care

Wound care

Phone numbers

When to call the doctor

Time of discharge

a.

Kardex form

b.

Admission nursing history

c.

Mode of transportation

d.

SOAP notes

ANS: C

List actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. In some settings, a Kardex, a portable flip-over file or notebook, is kept at the nurses station. A Kardex is for nurses, not for patients to take upon discharge. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style.

DIF: Evaluate REF: 353| 356

OBJ: Identify elements to include when documenting a patients discharge plan.

TOP: Evaluation MSC: Communication and Documentation

15. A home health nurse is preparing for an initial home visit. Which information should be included in the patients home care medical record?

a.

Nursing process form

b.

Step-by-step skills manual

c.

A list of possible procedures

d.

Reports to third party payers

ANS: D

Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third party payers. An interprofessional plan of care is used rather than a nursing process form. A step-by-step skills manual and a list of possible procedures are not included in the record.

DIF: Understand REF: 357

OBJ: Identify the important aspects of home care and long-term care documentation.

TOP: Planning MSC: Communication and Documentation

16. A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning and for meeting quality improvement within and across facilities. Which task did the nurse just complete?

a.

A focused assessment/specific body system

b.

The Resident Assessment Instrument/Minimum Data Set

c.

An admission assessment and acuity level

d.

An intake assessment form and auditing phase

ANS: B

You assess each resident in a long-term care agency receiving funding from Medicare and Medicaid programs using the Resident Assessment Instrument/Minimum Data Set (RAI/MDS). This documentation provides standardized protocols for assessment and care planning and a minimum data set to promote quality improvement within and across facilities. A focused assessment is limited to a specific body system. An admission assessment and acuity level is performed in the hospital. An intake assessment is for home health. There is no such thing as an auditing phase.

DIF: Remember REF: 357

OBJ: Identify the important aspects of home care and long-term care documentation.

TOP: Implementation MSC: Communication and Documentation

17. A nurse is giving a hand-off report to the oncoming nurse. Which information is critical for the nurse to report?

a.

The patient had a good day with no complaints.

b.

The family is demanding and argumentative.

c.

The patient has a new pain medication, Lortab.

d.

The family is poor and had to go on welfare.

ANS: C

Relay to staff significant changes in the way therapies are to be given (e.g., different position for pain relief, new medication). Dont simply describe results as good or poor. Be specific. Dont use critical comments about patients or familys behavior, such as Mrs. Wills is so demanding. Dont engage in idle gossip.

DIF: Apply REF: 357

OBJ: Describe the purpose and content of a change-of-shift report.

TOP: Implementation MSC: Communication and Documentation

18. A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart. What is the preceptors best response?

a.

A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care.

b.

A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs.

c.

A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities.

d.

A change-of-shift report provides important information to caregivers and develops relationships within the health care team.

ANS: A

Properly performed, a hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care. Reimbursement costs and research priorities/opportunities are functions of the medical record. The purpose of the change-of-shift report is not to establish relationships but to ensure patient safety and continuity of care.

DIF: Remember REF: 349| 358

OBJ: Describe the purpose and content of a change-of-shift report.

TOP: Implementation MSC: Management of Care

19. A nurse is preparing a change-of-shift report for a patient who had chest pain. Which information is critical for the nurse to include?

a.

Pupils equal and reactive to light

b.

The family is a pain

c.

Had poor results from the pain medication

d.

Sharp pain of 8 on a scale of 1 to 10

ANS: D

Elements in a change-of-shift report include identification of significant changes in measurable terms (e.g., pain scale) and by observation. Report elements do not include normal findings or routine information retrievable from other sources or derogatory or inappropriate comments about the patient or family, which could possibly lead to legal charges if overheard by the patient or family. This kind of language contributes to prejudicial opinions about the patient. Dont simply describe results as good or poor. Be specific.

DIF: Understand REF: 357-358

OBJ: Describe the purpose and content of a change-of-shift report.

TOP: Planning MSC: Communication and Documentation

20. Which situation will require the nurse to obtain a telephone order?

a.

As the nurse and primary care provider leave a patients room, the primary care provider gives the nurse an order.

b.

At 0100, a patients blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood.

c.

At 0800, the nurse and primary care provider make rounds and the primary care provider tells the nurse a diet order.

d.

A nurse reads an order correctly as written by the primary care provider in the patients medical record.

ANS: B

A registered nurse makes a telephone report when significant events or changes in a patients condition have occurred. Telephone orders and verbal orders usually occur at night or during emergencies. Because the time is 1AM (0100 military time) and the primary care provider is not present, the nurse will need to call the primary care provider for a telephone order. A verbal order (VO) involves the health care provider giving orders to a nurse while they are standing near each other. Just reading an order that is correctly written in the chart does not require a telephone order.

DIF: Apply REF: 358

OBJ: Explain when to take and how to verify telephone orders.

TOP: Assessment MSC: Communication and Documentation

21. A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?

a.

12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.

b.

12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN, read back.

c.

12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.

d.

12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN.

ANS: C

The nurse receiving a TO writes down the complete order or enters it into the computer as it is being given. Then he or she reads the order back to the health care provider, called read back, and receives confirmation from the person who gave the order that it is correct. An example follows: 10/16/2011: 0815, Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Knight/J. Woods, RN, read back. VO stands for verbal order, not telephone order. The doctors name and read back must be included in the chart entry.

DIF: Apply REF: 358

OBJ: Explain when to take and how to verify telephone orders.

TOP: Implementation MSC: Communication and Documentation

22. A nurse has taught the staff about informatics. Which statement indicates that the staff needs more education?

a.

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

b.

To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice.

c.

A nurse needs to know how to acquire, critique, and apply scientific evidence from literature databases.

d.

Nursing informatics integrates nursing science, computer science, and information science to manage and communicate information in nursing practice.

ANS: A

If the staff needs more education, then an incorrect statement is made. Competence in informatics is not the same as computer competency. To become competent in informatics, you need to be able to use evolving methods of discovering, retrieving, and using information in practice. This means that you learn to recognize when information is needed and have the skills to find, evaluate, and use that information effectively. For example, you need to know how to acquire, critique, and apply scientific evidence from literature databases. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.

DIF: Understand REF: 359

OBJ: Discuss the relationship between informatics and quality health care.

TOP: Evaluation MSC: Management of Care

23. 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?

a.

Clinical decision support system

b.

Nursing process design

c.

Critical pathway design

d.

Computerized provider order entry system

ANS: C

One design model for Nursing Information Systems (NIS) is the protocol or critical pathway design. With this design, all health care providers use a protocol system to document the care they provide. A clinical decision support system is based on rules and if-then statements, linking information and/or producing alerts, warnings, or other information for the user. The nursing process design is the most traditional design for an NIS. This design organizes documentation within well-established formats such as admission and postoperative assessments, problem lists, care plans, discharge planning instructions, and intervention lists or notes. Computerized provider order entry (CPOE) is a process by which the health care provider directly enters orders for patient care into the hospital information system.

DIF: Understand REF: 360| 362

OBJ: Discuss the relationship between informatics and quality health care.

TOP: Evaluation MSC: Communication and Documentation

24. A nurse wants to reduce data entry errors on the computer system. Which behavior should the nurse implement?

a.

Use the same password all the time.

b.

Share password with only one other staff member.

c.

Print out and review computer nursing notes at home.

d.

Chart on the computer immediately after care is provided.

ANS: D

To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patients bedside to facilitate immediate documentation of information as it is collected from a patient. A good system requires frequent and random changes in personal passwords to prevent unauthorized persons from tampering with records. When using a health care agency computer system, it is essential that you do not share your computer password with anyone under any circumstances. You destroy (e.g., shred) anything that is printed when the information is no longer needed. Taking nursing notes home is a violation of the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality.

DIF: Apply REF: 352| 361 OBJ: Identify ways to reduce data entry errors.

TOP: Implementation MSC: Communication and Documentation

25. 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. Call bell within reach. Bed monitor on.

-Jane More, RN

0810 Notified primary care provider of patients 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

a.

0800

b.

0810

c.

0815

d.

0830

ANS: D

Note that you do not include mention of the incident report in the patients medical record. Instead you document in the patients medical record an objective description of what happened, what you observed, and follow-up actions taken. It is important to evaluate and document the patients response to the error or incident. Always contact the patients health care provider whenever an incident happens.

DIF: Analyze REF: 358

OBJ: Describe interdisciplinary communication within the health care team.

TOP: Evaluation MSC: Management of Care

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

a.

Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse ox 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.

b.

Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, felt better. Finally, patient had no complaints.

c.

Breathing without difficulty. Sitting up in bed watching TV. Had a good day.

d.

Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.

ANS: A

Accurate documentation of supplies and equipment used assists in accurate and timely reimbursement. Your documentation clarifies the type of treatment a patient receives and supports reimbursement to the health care agency. None of the other options had equipment or supplies listed. Avoid using generalized, empty phrases such as status unchanged or had a good day. Do not enter personal opinionsstating that the patient is cooperative is a personal opinion and should be avoided. Finally, patient had no complaints is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care.

DIF: Analyze REF: 350-351

OBJ: Discuss the relationship between documentation and financial reimbursement for health care.

TOP: Implementation MSC: Communication and Documentation

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

a.

Sentinel events help determine reimbursement issues for health care.

b.

Home health, long-term care, and hospital nurses documentation can affect reimbursement for health care.

c.

A clinical information system must be installed by 2014 to obtain health care reimbursement.

d.

HIPAA is the basis for establishing reimbursement for health care.

ANS: B

Nurses documentation practices in home health, long-term care, and hospitals can determine reimbursement for health care. Sentinel events do not determine reimbursement. About 60% of the worst types of medical errors, called sentinel events (involving death or severe physical/psychological injury), relate to communication problems that often arise during telephone reports. A clinical information system (CIS) does not have to be installed by 2014 to obtain reimbursement. CIS programs include monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems. Diagnosis-related groups (DRGs) are the basis for establishing reimbursement for patient care, not HIPAA. Legislation to protect patient privacy regarding health information is the Health Insurance Portability and Accountability Act (HIPAA).

DIF: Understand REF: 349-350| 357-358| 361

OBJ: Discuss the relationship between documentation and financial reimbursement for health care.

TOP: Implementation MSC: Management of Care

28. A nurse is discussing the advantages of standardized documentation forms in the nursing information system. Which advantage should the nurse describe?

a.

Varied clinical databases

b.

Reduced errors of omission

c.

Increased hospital costs

d.

More time to read charts

ANS: B

Advantages associated with the nursing information system include increased time to spend with patients (not more time to read charts); better access to information; enhanced quality of documentation; reduced errors of omission; reduced, not increased, hospital costs; increased nurse job satisfaction; compliance with requirements of accrediting agencies (e.g., TJC); and development of a common, not varied, clinical database.

DIF: Understand REF: 360

OBJ: Discuss the advantages of standardized documentation forms.

TOP: Implementation MSC: Communication and Documentation

MULTIPLE RESPONSE

1. Which behaviors indicate that the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)

a.

Writes the patients room number and date of birth on a paper for school

b.

Prints/copies material from the patients health record for a graded care plan

c.

Reviews assigned patients record and another unassigned patients record

d.

Reads the progress notes of assigned patients record

e.

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

f.

Discusses patient care with the hospital volunteer

ANS: D, E

When you are a student in a clinical setting, confidentiality and compliance with HIPAA are part of professional practice. Reading the progress notes of an assigned patients record and giving a change-of-shift report to the oncoming nurse about the patient are behaviors that follow HIPAA and confidentiality guidelines. Students and health care professionals may not discuss a patients examination, observation, conversation, diagnosis, or treatment with other patients or staff not involved in the patients care. To protect patient confidentiality, ensure that written materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information), and never print material from an electronic health record for personal use.

DIF: Remember REF: 349

OBJ: Identify ways to maintain confidentiality of electronic and written records.

TOP: Planning MSC: Communication and Documentation

2. Identify the purposes of a health care record. (Select all that apply.)

a.

Communication

b.

Legal documentation

c.

Reimbursement

d.

Education

e.

Research

f.

Nursing process

ANS: A, B, C, D, E

The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing (reimbursement), education, research, and auditing/monitoring. Nursing process is a way of thinking and performing nursing care; it is not a purpose of a health care record.

DIF: Remember REF: 349 OBJ: Identify purposes of a health care record.

TOP: Planning MSC: Communication and Documentation

3. A nurse is creating a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)

a.

Create a password with just letters.

b.

Bypass the firewall.

c.

Use a programmed speed-dial key when faxing.

d.

Implement an automatic sign-off.

e.

Impose disciplinary actions for inappropriate access.

f.

Shred papers containing personal health information (PHI).

ANS: C, D, E, F

When faxing, use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. An automatic sign-off is a safety mechanism that logs a user off the computer system after a specified period of inactivity. An automatic sign-off is used in most patient care areas and other departments that handle sensitive data. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information. All papers containing PHI (e.g., Social Security number, date of birth or age, patients name or address) must be destroyed. Most agencies have shredders or locked receptacles for shredding and later incineration. Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. A firewall is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information and should not be bypassed.

DIF: Create REF: 361 OBJ: Identify ways to reduce data entry errors.

TOP: Evaluation MSC: Communication and Documentation

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