14 Questions
What is one of the purposes of the health record assessment?
To compare objective and subjective assessment data
How does the patient record serve the purpose of quality assurance?
By enabling medical record audits to determine standards of care
What is a significant aspect of the patient record with regards to reimbursement?
Providing the basis for decisions regarding care and subsequent reimbursement
How does accurate documentation in patient records contribute to research?
By ensuring that research outcomes are valid and reliable
What is the primary purpose of maintaining confidentiality in nursing documentation?
To protect the patient's privacy and comply with legal and ethical requirements
Why should students de-identify any patient information in written assignments?
To ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA)
What is the main guideline for nursing documentation to maintain accuracy?
Proofreading to ensure correct spelling and use of medical terms
Why should direct quotes of patient statements be used in nursing documentation?
To maintain objectivity, especially when documenting psychosocial and mental health issues
What is the significance of documenting information chronologically?
It ensures that important information is not forgotten
Why should only commonly accepted and approved abbreviations be used in nursing documentation?
To ensure that all healthcare professionals understand the abbreviations
Why is the standardized vocabulary important in the electronic health record?
To facilitate the retrieval of individual and aggregate data
What is the goal of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act?
To increase patients’ access to their own medical records
What do clinical surveillance tools do in relation to electronic health record data?
They produce real-time patient risk scores for designated high-risk conditions
What does the Universal Computer-Based Patient Record aim to achieve?
Increase patients’ access to their own medical records
This quiz covers the purposes of health records and patient records, including their role in care planning and legal documentation. It also explores the comparison of objective and subjective assessment data for determining health status and progress.
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