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Mock-Ch.26-Informatics and Documentation
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Mock-Ch.26-Informatics and Documentation

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Questions and Answers

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

  • Reviewing the patient’s medical record
  • Documenting medication administered to the patient
  • Reading the patient’s plan of care
  • Sharing patient information with another student (correct)
  • A nurse exchanges information with the oncoming nurse about a patient’s care. Which action did the nurse complete?

  • A referral
  • An acuity rating
  • A verbal report (correct)
  • An electronic record entry
  • A nurse is auditing and monitoring patients’ health records. Which action is the nurse taking?

  • Determining the degree to which standards of care are met by reviewing patients’ health records (correct)
  • Realizing that care not documented in patients’ health records still qualifies as care provided
  • Basing reimbursement upon the diagnosis-related groups documented in patients’ records
  • Comparing data in patients’ records to determine whether a new treatment had better outcomes than the standard treatment
  • After providing care, a nurse charts in the patient’s record. Which entry will the nurse document?

    <p>Skin pale and cool.</p> Signup and view all the answers

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

    <p>Left knee incision 1 inch in length without redness, drainage, or edema.</p> Signup and view all the answers

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

    <p>Charts consecutively on every other line.</p> Signup and view all the answers

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

    <p>Charts in a legible manner.</p> Signup and view all the answers

    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?

    <p>Electronic health record</p> Signup and view all the answers

    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?

    <p>Demonstrated use of crutches</p> Signup and view all the answers

    A nurse wants to find the daily weights of a hospitalized patient. Which resource will the nurse consult?

    <p>Graphic record and flow sheet</p> Signup and view all the answers

    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?

    <p>Document the variance in the patient’s record.</p> Signup and view all the answers

    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?

    <p>Upon admission</p> Signup and view all the answers

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

    <p>Community resources</p> Signup and view all the answers

    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

    <p>Mode of transportation</p> Signup and view all the answers

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

    <p>Reports to third-party payers</p> Signup and view all the answers

    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?

    <p>A minimum data set</p> Signup and view all the answers

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

    <p>The patient received a pain medication.</p> Signup and view all the answers

    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?

    <p>Home health</p> Signup and view all the answers

    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?

    <p>Reports sharp pain of 8 on a scale of 1 to 10.</p> Signup and view all the answers

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

    <p>Read back the order as written to the health care provider for verification.</p> Signup and view all the answers

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

    <p>12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.</p> Signup and view all the answers

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

    <p>If a nurse has computer competency, the nurse is competent in informatics.</p> Signup and view all the answers

    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?

    <p>Critical pathway design</p> Signup and view all the answers

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

    <p>Chart on the computer immediately after care is provided.</p> Signup and view all the answers

    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

    <p>0830</p> Signup and view all the answers

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

    <p>Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.</p> Signup and view all the answers

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

    <p>Home health, long-term care, and hospital nurses’ documentation can affect reimbursement for health care.</p> Signup and view all the answers

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

    <p>Reduced errors of omission</p> Signup and view all the answers

    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.)

    <p>Gives a change-of-shift report to the oncoming nurse about the patient.</p> Signup and view all the answers

    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.)

    <p>Reimbursement</p> Signup and view all the answers

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

    <p>Implement an automatic sign-off.</p> Signup and view all the answers

    Study Notes

    Nurse Preceptor and Student Nurse

    • A nurse preceptor will intervene if a student nurse exhibits unsafe behavior or fails to follow proper procedure.

    Nursing Responsibilities

    • A nurse exchanges information with the oncoming nurse about a patient's care to ensure continuity of care.
    • A nurse audits and monitors patients' health records to ensure accuracy and completeness.
    • A nurse charts in a patient's record after providing care to document interventions and outcomes.

    Charting and Documentation

    • A nurse documents the care provided to a patient in the patient's record.
    • A nurse charts the patient's response to care, such as the use of crutches, in the patient's record.
    • A nurse must document all interventions and outcomes in the patient's record.

    Critical Pathways

    • A critical pathway outlines the expected course of treatment and care for a patient.
    • A nurse uses a critical pathway to ensure a patient is receiving timely and appropriate care.

    Discharge Planning

    • A nurse begins discharge planning for a patient upon admission to ensure a smooth transition to home or another care setting.
    • A nurse includes information on medication, diet, activity level, follow-up care, and wound care in a patient's discharge summary.
    • A nurse adds phone numbers and instructions on when to call the doctor to a patient's discharge summary.

    Home Health Care

    • A home health nurse includes information on the patient's medical history, current condition, and care plan in the patient's home care medical record.

    Standardized Protocols

    • A nurse completes standardized protocols for assessment and care planning to ensure reimbursement from Medicare and Medicaid.

    OASIS Data Set

    • A nurse completes an Outcome and Assessment Information Set (OASIS) data set on a patient to assess and document the patient's condition.

    Informatics

    • A nurse teaches staff about informatics to improve data management and reduce errors.
    • A nurse uses a computer system with a protocol system to document patient care.
    • A nurse takes steps to reduce data entry errors, such as using automated systems and double-checking entries.

    Confidentiality and HIPAA

    • A nurse maintains confidentiality by not sharing patient information without authorization.
    • A nurse includes information on confidentiality and HIPAA in teaching sessions on health care reimbursement.

    Health Care Records

    • A nurse includes information on the purposes of a health care record, such as continuity of care, reimbursement, and research, in teaching sessions.
    • A nurse develops a plan to reduce data entry errors and maintain confidentiality by following guidelines and protocols.

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    Quiz Team

    Description

    This quiz assesses the situation where a nurse preceptor is working with a student nurse and identifies the behavior that requires the nurse preceptor to intervene.

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