30 Questions
What is the purpose of classifying patients by age, diagnosis, and surgical procedure in the hospital?
To predict the use of hospital resources and determine a fixed payment amount
Why do payers review patient medical charts?
To determine whether necessary and ordered care is being given
Who owns the original patient health record?
The physician or institution
Why is detailed charting important in patient health records?
To protect healthcare professionals from liability
What is the purpose of sharing examples of good charting with students in healthcare professions?
To help them learn from examples of good practice
What is a potential use of patient health records in court proceedings?
As legal documents to support or refute claims
What is a concern surrounding the Personal Health Record (PHR)?
The patient's ability to manually update it
What can patients typically do through patient portals?
Send messages to healthcare providers
What is a key difference between a PHR and a patient portal?
A PHR allows patients to add their own health information, while a patient portal does not
When are lab and diagnostic results visible to patients through patient portals?
Only after the healthcare provider has viewed and released the information
What type of information is typically available through patient portals?
A range of health information, including lab and radiology results and medication lists
What is a significant advantage of Electronic Health Records (EHRs) over traditional records?
They eliminate repetitive entries and allow more freedom of access to the database
What is a common feature of most healthcare systems?
Patient portals that provide access to health information
What is one of the purposes of the government publishing data on certain diseases?
To evaluate the effectiveness of new treatments
Why is it important to hold patient information confidential?
To protect the patient's privacy and rights
What is an advantage of EHRs in terms of documentation?
They increase the legibility of documentation
What type of information can be found in EHRs?
Information identical to that found in traditional records
Why is data regarding the length of hospitalization and treatment costs important for health insurance providers?
To contain or limit health care costs
What is the purpose of informing patients and their family members about handheld systems?
To prevent the perception that staff are using personal cell phones during their shift
What is the advantage of charting at the bedside?
It saves time and makes current information immediately available
How do some electronic health record systems reduce duplicate effort?
By automatically retrieving and condensing information from electronic devices
What is the primary purpose of adding an 'R' to the SBAR method of communication?
To ensure the nurse understands the order correctly
What is the primary purpose of standardized phrases in electronic charting?
To indicate specific information and facilitate standardized documentation
What is the term used to describe wheeled carts housing point-of-care (POC) systems?
Computers on wheels
What is a crucial aspect of nursing notes?
They have a decisive impact on communication and patient care
What is the primary benefit of electronic charting systems that prompt for certain data to be entered?
They result in more accurate and complete record keeping
Who has primary responsibility for a patient's initial admission nursing history?
The Registered Nurse (RN)
What is the purpose of using ISBARR in communication?
To ensure the nurse reads back orders to the healthcare provider
What is essential for the LPN/LVN when entering patient information?
To enter information received, concise, complete, and accurate
Why are correct spelling, grammar, and punctuation important in nursing notes?
To avoid confusion and errors in patient care
Understand the patient classification system used in healthcare to predict hospital resource utilization and set payment rates. Learn about the 25 major diagnostic categories and hundreds of sub-categories used by private insurance companies and government programs.
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