Patient Classification System Quiz and Flashcards

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Questions and Answers

What is the purpose of classifying patients by age, diagnosis, and surgical procedure in the hospital?

To assign nurses to specific patient groups

To prioritize patients based on the severity of their condition

To predict the use of hospital resources and determine a fixed payment amount (correct)

To create a hierarchical system of patient categorization

Why do payers review patient medical charts?

To assess the performance of healthcare professionals

To determine whether necessary and ordered care is being given (correct)

To evaluate the quality of patient care

To identify areas for cost reduction

Who owns the original patient health record?

The healthcare system

The insurance company

The physician or institution (correct)

The patient

Why is detailed charting important in patient health records?

To protect healthcare professionals from liability Signup and view all the answers

What is the purpose of sharing examples of good charting with students in healthcare professions?

To help them learn from examples of good practice Signup and view all the answers

What is a potential use of patient health records in court proceedings?

As legal documents to support or refute claims Signup and view all the answers

What is a concern surrounding the Personal Health Record (PHR)?

The patient's ability to manually update it Signup and view all the answers

What can patients typically do through patient portals?

Send messages to healthcare providers Signup and view all the answers

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 Signup and view all the answers

When are lab and diagnostic results visible to patients through patient portals?

Only after the healthcare provider has viewed and released the information Signup and view all the answers

What type of information is typically available through patient portals?

A range of health information, including lab and radiology results and medication lists Signup and view all the answers

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 Signup and view all the answers

What is a common feature of most healthcare systems?

Patient portals that provide access to health information Signup and view all the answers

What is one of the purposes of the government publishing data on certain diseases?

To evaluate the effectiveness of new treatments Signup and view all the answers

Why is it important to hold patient information confidential?

To protect the patient's privacy and rights Signup and view all the answers

What is an advantage of EHRs in terms of documentation?

They increase the legibility of documentation Signup and view all the answers

What type of information can be found in EHRs?

Information identical to that found in traditional records Signup and view all the answers

Why is data regarding the length of hospitalization and treatment costs important for health insurance providers?

To contain or limit health care costs Signup and view all the answers

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 Signup and view all the answers

What is the advantage of charting at the bedside?

It saves time and makes current information immediately available Signup and view all the answers

How do some electronic health record systems reduce duplicate effort?

By automatically retrieving and condensing information from electronic devices Signup and view all the answers

What is the primary purpose of adding an 'R' to the SBAR method of communication?

To ensure the nurse understands the order correctly Signup and view all the answers

What is the primary purpose of standardized phrases in electronic charting?

To indicate specific information and facilitate standardized documentation Signup and view all the answers

What is the term used to describe wheeled carts housing point-of-care (POC) systems?

Computers on wheels Signup and view all the answers

What is a crucial aspect of nursing notes?

They have a decisive impact on communication and patient care Signup and view all the answers

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 Signup and view all the answers

Who has primary responsibility for a patient's initial admission nursing history?

The Registered Nurse (RN) Signup and view all the answers

What is the purpose of using ISBARR in communication?

To ensure the nurse reads back orders to the healthcare provider Signup and view all the answers

What is essential for the LPN/LVN when entering patient information?

To enter information received, concise, complete, and accurate Signup and view all the answers

Why are correct spelling, grammar, and punctuation important in nursing notes?

To avoid confusion and errors in patient care Signup and view all the answers

Study Notes

Patient Classification in Hospitals

Classifying patients by age, diagnosis, and surgical procedure aids in resource allocation, tailored care, and accurate billing.
Payers review patient medical charts for claims verification, care necessity assessment, and adherence to guidelines.

Ownership and Importance of Health Records

Original patient health records are owned by the healthcare provider, while patients have rights to access their information.
Detailed charting in health records ensures accurate documentation, continuity of care, and legal protection.

Educational Aspects of Charting

Sharing examples of good charting with healthcare students promotes learning effective documentation practices and clinical decision-making.
Patient health records may serve as evidence in court, especially in malpractice cases or disputes over care quality.

Personal Health Records (PHR) and Patient Portals

A concern with Personal Health Records (PHR) is the potential for data security breaches and unauthorized access.
Patient portals typically offer access to lab results, medication lists, appointment schedules, and direct communication with providers.

Differences in Health Record Access

A key difference between a PHR and a patient portal is that a PHR is typically managed by the patient, while a patient portal is healthcare provider-controlled.
Lab and diagnostic results become visible to patients through patient portals often as soon as they're finalized.

Information and Benefits of Electronic Health Records (EHR)

Information commonly available through patient portals includes medical history, vaccination records, and billing information.
EHRs enhance patient safety, streamline workflows, and improve coordination of care compared to traditional paper records.

Government and Confidentiality in Health Data

Government publishing data on certain diseases aims to promote public health awareness and inform research.
Patient information confidentiality is crucial to protect privacy, maintain trust, and comply with legal regulations.

Advantages of EHRs and Documentation Practices

An advantage of EHRs is improved accuracy in documentation, reducing errors linked to handwriting interpretation.
EHRs include comprehensive patient information such as medical history, lab results, and treatment plans.

Financial Considerations for Health Insurance Providers

Data on hospitalization length and treatment costs is essential for health insurance providers to assess risk and establish premiums.
Informing patients and families about handheld systems enhances understanding of technology in care and engagement in health management.

Bedside Charting and Efficiencies

Charting at the bedside improves accuracy and timeliness of documentation, fostering better patient interactions.
Some EHR systems reduce duplicate efforts by integrating and automating data entry tasks across multiple departments.

Communication Standards in Healthcare

The addition of an 'R' to the SBAR method reinforces the significance of recommendations in structured communication.
Standardized phrases in electronic charting enhance clarity, streamline documentation, and reduce variability.

Point-of-Care Systems and Nursing Responsibilities

Wheeled carts housing point-of-care (POC) systems are referred to as "workstations on wheels" (WOW) for portable access to health records.
A crucial aspect of nursing notes is capturing patient observations accurately and comprehensively for effective care delivery.

Benefits of Electronic Charting

Electronic charting systems that prompt for specific data entry significantly reduce missed information and promote thorough documentation practices.
The primary responsibility for a patient's initial admission nursing history typically lies with registered nurses (RNs).

Effective Communication in Nursing

ISBARR (Introduction, Situation, Background, Assessment, Recommendation, Repeat) is used for structured communication, enhancing clarity in handoffs.
LPNs/LVNs must ensure accuracy when entering patient information to maintain quality care and prevent errors.

Importance of Accuracy in Nursing Notes

Correct spelling, grammar, and punctuation in nursing notes are vital for clarity, professionalism, and legal comprehensibility of the documentation.

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Description

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.

Fundamentals of Nursing: Patient Classification System

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