Mock-Ch.26-Informatics and Documentation

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

A nurse exchanges information with the oncoming nurse about a patient’s care. Which action did the nurse complete?

A nurse is auditing and monitoring patients’ health records. Which action is the nurse taking?

After providing care, a nurse charts in the patient’s record. Which entry will the nurse document?

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

Which action by a novice nurse will cause the preceptor to provide follow up instructions?

Which action can the nurse take legally when charting on a patient’s record?

A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse access?

A nurse has instructed the patient regarding the proper use of 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 nurse wants to find the daily weights of a hospitalized patient. Which resource will the nurse consult?

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

A nurse developed the following discharge summary sheet. Which critical information should the nurse add? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge

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

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing?

A nurse is charting. Which event is critical for the nurse to document? The family is demanding and argumentative.

A nurse is completing an Outcome and Assessment Information Set (OASIS) data set on a patient. The nurse works in which area of patient care?

A nurse is preparing to document a patient who has reported chest pain. Which information provided by the patient is critical for the nurse to include?

Which action will the nurse take when taking a telephone order?

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

A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up?

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 nurse wants to reduce data entry errors on the computer system. Which action should the nurse take?

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. Nurse call system within reach. Bed monitor on. —Jane More, RN 0810 Notified primary care provider of patient’s 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 patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement?

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

A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe?

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

A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.)

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