82 Questions
What is the primary purpose of documentation in a patient's health record?
To provide a written account of patient data, clinical decisions, and interventions
What is the role of documentation in ensuring continuity of care?
It facilitates communication among healthcare team members in all settings
What type of data is tracked in a patient's health record?
All nursing care provided, including assessment data, nursing problems, interventions, and evaluation of patient responses
Why is it essential to document all nursing care provided?
To provide accountability for care delivered
What is the primary function of a health record?
To document all aspects of patient care
Who can access and review a patient's health record?
All members of the healthcare team in all settings
What is the relationship between documentation and the quality of care delivered?
Documentation provides a detailed account of the level of quality of care delivered
Why is it necessary to maintain accurate and up-to-date documentation?
All of the above
What should you do with printed materials containing PHI when they are no longer needed?
Destroy them by shredding or placing in a locked receptacle
Why should nursing students not print information from the health record to take away from the clinical agency?
To maintain confidentiality of patient data
How should nurses handle patient data that is transcribed onto forms or used for academic papers?
De-identify the data
What should be done with papers containing PHI after use or faxing?
Destroy them through shredding or disposal in a locked receptacle
What is a responsibility of nurses when using computer hard drives?
Erasing files that contain PHI
What should health care agencies and departments have regarding fax machines?
A policy for the use of fax machines
What limitation should be placed on information sent by fax?
Do not exceed what was requested or required for immediate clinical needs
How should patient information be transcribed for clinical assignments?
Transcribe only necessary information directly from the computer screen or physical chart
What is one of the primary purposes of data entered into the healthcare record?
Facilitating financial billing and reimbursement of care
What is a critical aspect of documentation in healthcare?
Documenting patient care in a timely manner
What is a potential consequence of incomplete or illegible records?
Malpractice claims
What is the primary function of the healthcare record?
Providing a legal record of care
Why is accurate documentation important in healthcare?
To reduce liability for healthcare providers
What is a benefit of documenting patient care in a timely manner?
Reduced liability for healthcare providers
What is a potential consequence of failing to document nursing actions?
Malpractice claims
What is a primary responsibility of healthcare providers?
Documenting patient care
What is a key feature of the healthcare record?
It is a confidential and permanent document
Why is the healthcare record an important means of communication?
It provides a clear and accurate account of patient care
What is the primary purpose of accurate documentation of nursing services provided?
To determine payment or reimbursement for health care services
What is the role of a quality improvement (QI) nurse in auditing health records?
To determine whether nurses consistently and accurately document implementation of fall precautions
What is the benefit of reading the record of a patient for whom you are assigned to care?
To learn the nature of a patient's condition and response to treatment
What is the purpose of de-identified data obtained from health records?
To support research studies on health care problems
What is the requirement for using an electronic health record system (EHRS) according to the concept of meaningful use?
All of the above
What is the primary difference between an electronic health record (EHR) and an electronic medical record (EMR)?
EHR is for a patient's lifetime record, while EMR is for an individual visit
What is a unique feature of an electronic health record (EHR)?
It integrates all patient information into one record, regardless of the number of times a patient enters a health care system
What is the purpose of an institutional review board (IRB) in a health care agency or hospital?
To approve research studies on health care problems
What is the role of audits of health records in health care?
To offer information on recurrent health care problems and specific patient incidents
What is the benefit of analyzing de-identified data obtained from health records?
To contribute to evidence-based nursing practice and high-quality health care
What is one of the key advantages of an EHR for nursing?
Comparing current clinical data about a patient with data from previous health care encounters
Under HIPAA, what is required to eliminate barriers that potentially delay access to care?
Notifying patients of privacy policies and obtaining written acknowledgment
When can nurses use health records for data gathering, research, or continuing education?
As long as records are used as specified and permission is granted from an institutional review board
What is the responsibility of all persons working in healthcare under HIPAA?
Ensuring appropriate access to and confidentiality of personal health information
What is a firewall in a computer information system?
A combination of hardware and software that protects private network resources from outside hackers
What is essential to safeguard when using a health care agency computer system?
Safeguarding any information that is printed from the record or extracted for report purposes
What is a characteristic of strong passwords?
Using combinations of letters, numbers, and symbols that are difficult to guess
What is required when using a health care agency computer system?
Frequently changing personal passwords to prevent unauthorized persons from tampering with records
What is individually identifiable information relating to an individual's past, present, or future health status?
Personal health information
Why is it essential to maintain patient confidentiality?
To ensure appropriate access to and confidentiality of personal health information
What is the primary purpose of acuity rating systems in healthcare?
To determine the hours of care and number of staff required for a given group of patients
What is the focus of Health Information Technology (HIT)?
The patient and the process of care
What is a clinical information system (CIS)?
A computerized database management system used to access patient data needed to plan, implement, and evaluate care
What is the benefit of using a computerized provider order entry (CPOE) system?
It improves productivity and cost-effectiveness in the communication and implementation of health care provider orders
What is the acuity level of a patient who requires frequent monitoring and extensive care after surgery?
3
What is the purpose of a health care information system (HIS)?
To make the entry and communication of data and information more efficient
What is the role of documentation in long-term care facilities?
To support an interprofessional approach to the assessment and planning process for all patients
What is an incident report in a patient's health care record used for?
To make the incident report part of the health care record and therefore admissible for attorney review
What is the role of a clinical information system (CIS) in healthcare?
To access patient data needed to plan, implement, and evaluate care
What is the benefit of accurate acuity ratings in healthcare?
They justify the number and qualifications of staff needed to safely care for patients
What advantage do NCISs offer to nurses in practice?
Better access to information
What is the purpose of a CDSS?
To aid in clinical decision making
What is nursing informatics?
A specialty that integrates nursing science, computer science, and information science
What is the benefit of NCISs for accrediting agencies?
Adherence to requirements of accrediting agencies
What type of design does an NCIS have?
Nursing process design and critical pathway design
What is the purpose of a protocol or critical pathway design in an NCIS?
To facilitate interprofessional management of information
What is the primary purpose of flow sheets in the EHR?
To quickly and easily enter patient assessment data
What is the benefit of a well-designed NCIS?
Enhanced quality of documentation
What is the purpose of an effective CDSS?
To notify health care providers of patient allergies
What is the philosophy behind charting by exception (CBE)?
All standards for normal assessment findings are met unless otherwise documented
What is the purpose of a nursing history form?
To guide the nurse through a comprehensive assessment to identify relevant nursing diagnoses or problems
What type of information can be seen in flow sheets?
Patient trends over time
Where can a nurse document additional detailed information about a patient's status and response to an activity?
In the narrative progress note or within the flow sheet
What is the purpose of narrative progress notes?
To monitor progress made toward resolving a patient's problems
What is the benefit of using flow sheets in the EHR?
They provide current patient information accessible to all members of the health care team
What is the role of well-designed flow sheets in the EHR?
They are a key part of a good exception-based documentation system
What is the primary purpose of completing a patient care summary document at the beginning and/or end of each shift?
To organize care and give a hand-off report
What is the benefit of using standardized care plans?
They improve continuity of care among professional nurses
What is included in a discharge summary document?
Medications, diet, community resources, and follow-up care
Why should telephone orders and verbal orders be used only when absolutely necessary?
Because they are error-prone and may be misheard
What information should be included when documenting a telephone order or verbal order?
The date and time of the call, the number called, and who made the call
What is the purpose of incident reports?
To document an objective description of what happened and the follow-up actions taken
What should be done when documenting an incident report?
Evaluate and document the patient's response to the incident in the health care record
Why is it important to involve the patient and family in the discharge planning process?
To ensure that they have the necessary information and resources to return home or move to the next level of care
What is the purpose of interprofessional discharge planning?
To develop a comprehensive plan for a safe discharge
What is the benefit of documenting the patient's care in a timely manner?
It ensures that the patient's care is well-coordinated and continuous
Study Notes
Documentation in Nursing Practice
- Documentation is a vital aspect of nursing practice, producing a written account of patient data, clinical decisions, and interventions in a health record.
- It is a key communication strategy that facilitates continuity of care, tracks patient outcomes, and provides accountability for care provided.
Importance of Documentation
- Documentation is essential for:
- Quality of care: provides a detailed account of the level of care delivered.
- Standards of regulatory agencies and nursing practice: ensures compliance with regulations and standards.
- Reimbursement: supports financial billing and reimbursement for care provided.
- Legal guidelines: provides a legal record of care, justifying financial billing and reimbursement.
- Interprofessional communication: facilitates communication among health care providers.
- Education and research: serves as a resource for nursing and health care education and research.
Health Care Record
- The health care record is a:
- Valuable source of data for health care providers.
- Resource for education and research.
- Permanent, legal documentation of patient information.
- Confidential and accurate account of patient health care status.
- It is available to all members of the health care team, allowing for:
- Safe and effective clinical decision-making.
- Identification of patterns and trends in patient care.
- Development of clinical knowledge.
Electronic Health Record (EHR)
- An EHR is an individual's lifetime computerized record, integrating all patient information into one record.
- It includes:
- Results of diagnostic studies, including images.
- Decision support software programs.
- Ability to store unlimited patient records.
- EHR benefits for nursing include:
- Comparing current clinical data with previous health care encounters.
- Maintaining ongoing symptom management.
- Providing an ongoing record of health education.
Confidentiality and Security
- Nurses must protect patient confidentiality and adhere to HIPAA guidelines.
- Ensuring appropriate access to and confidentiality of personal health information is the responsibility of all health care professionals.
- Security measures include:
- Firewalls.
- Antivirus and spyware-detection software.
- Strong passwords and frequent changes.
- Physical and logical restrictions to protect information.
- Printed information from the record must be safeguarded and destroyed when no longer needed.
Electronic Health Record (EHR)
- Nurses use flow sheets to document patient physiological data and routine care, organized by body system
- Flow sheets provide current patient information accessible to all health care team members
- They facilitate quick identification of patient trends over time
Charting by Exception (CBE)
- Philosophy: all standards for normal assessment findings or routine care activities are met unless otherwise documented
- Well-designed flow sheets are a key part of a good exception-based documentation system within the EHR
Nursing Assessment and Care Plans
- Nursing history forms are used to identify relevant nursing diagnoses or problems at admission
- Computerized documentation systems generate a patient care summary document for each patient at the beginning and/or end of each shift
- Standardized care plans are useful for QI audits and improve continuity of care among professional nurses
Discharge Planning
- Interprofessional discharge planning begins at admission and involves identifying key clinical outcomes and timelines
- Discharge documentation includes medications, diet, community resources, follow-up care, and contact information
- The discharge summary document is printed out and given to the patient on discharge
Telephone Orders (TOs) and Verbal Orders (VOs)
- TOs and VOs should be used only when absolutely necessary
- A nurse receiving a TO or VO enters the complete order into the computer using CPOE software or writes it out on a physician’s order sheet
- The receiver of a VO or TO records it and reads it back to the prescriber to ensure accuracy
Incident Reports
- Incident reports contain confidential information and are limited to individuals responsible for reviewing the forms
- An objective description of the incident, observed events, and follow-up actions are documented in the patient’s health care record
- The patient’s response to the incident is also evaluated and documented
Acuity Rating Systems
- Acuity rating systems determine the hours of care and number of staff required for a given group of patients
- A patient’s acuity level is based on the type and number of nursing interventions required over a 24-hour period
- Acuity levels range from 1 (independent in all but one or two aspects of care) to 5 (totally dependent in all aspects of care)
Health Information Technology (HIT)
- HIT includes computer hardware and software dedicated to the collection, storage, processing, retrieval, and communication of patient care information
- A health care information system (HIS) consists of clinical and administrative information systems
- HIT enhances the quality and efficiency of care provided
Clinical Information Systems (CIS)
- A CIS is a large, computerized database management system that accesses patient data needed to plan, implement, and evaluate care
- CIS includes monitoring systems, order entry systems, laboratory, radiology, and pharmacy systems
- Computerized provider order entry (CPOE) system allows health care providers to directly enter standardized orders for patient care into a medical record
Nursing Clinical Information Systems (NCIS)
- NCIS incorporates nursing informatics principles to support nursing process activities and manage care delivery
- Two NCIS designs: nursing process design and protocol or critical pathway design
- NCIS offers advantages such as better access to information, enhanced quality of documentation, and increased nurse job satisfaction
This quiz assesses knowledge on the importance of documentation in nursing practice, including its purpose and the information included in a patient's health record. It covers the various formats of health records and the standards of nursing practice reflected in documentation systems.
Make Your Own Quizzes and Flashcards
Convert your notes into interactive study material.
Get started for free