CH 26- Informatics and Documentation
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Questions and Answers

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 (correct)
  • To ensure reimbursement for healthcare services
  • To reduce the risk of errors in patient care
  • To facilitate communication among healthcare team members

    • What is the role of documentation in ensuring continuity of care?

  • It is not necessary for ensuring continuity of care
  • It facilitates communication among healthcare team members in all settings (correct)
  • It is only necessary for nurse practitioners
  • It provides a detailed account of patient care only in hospital settings

    • What type of data is tracked in a patient's health record?

  • Only assessment data and nursing diagnoses
  • All nursing care provided, including assessment data, nursing problems, interventions, and evaluation of patient responses (correct)
  • Only patient outcomes and evaluation of care
  • Only medications and treatments administered

    • Why is it essential to document all nursing care provided?

    <p>To provide accountability for care delivered</p> Signup and view all the answers

    What is the primary function of a health record?

    <p>To document all aspects of patient care</p> Signup and view all the answers

    Who can access and review a patient's health record?

    <p>All members of the healthcare team in all settings</p> Signup and view all the answers

    What is the relationship between documentation and the quality of care delivered?

    <p>Documentation provides a detailed account of the level of quality of care delivered</p> Signup and view all the answers

    Why is it necessary to maintain accurate and up-to-date documentation?

    <p>All of the above</p> Signup and view all the answers

    What should you do with printed materials containing PHI when they are no longer needed?

    <p>Destroy them by shredding or placing in a locked receptacle</p> Signup and view all the answers

    Why should nursing students not print information from the health record to take away from the clinical agency?

    <p>To maintain confidentiality of patient data</p> Signup and view all the answers

    How should nurses handle patient data that is transcribed onto forms or used for academic papers?

    <p>De-identify the data</p> Signup and view all the answers

    What should be done with papers containing PHI after use or faxing?

    <p>Destroy them through shredding or disposal in a locked receptacle</p> Signup and view all the answers

    What is a responsibility of nurses when using computer hard drives?

    <p>Erasing files that contain PHI</p> Signup and view all the answers

    What should health care agencies and departments have regarding fax machines?

    <p>A policy for the use of fax machines</p> Signup and view all the answers

    What limitation should be placed on information sent by fax?

    <p>Do not exceed what was requested or required for immediate clinical needs</p> Signup and view all the answers

    How should patient information be transcribed for clinical assignments?

    <p>Transcribe only necessary information directly from the computer screen or physical chart</p> Signup and view all the answers

    What is one of the primary purposes of data entered into the healthcare record?

    <p>Facilitating financial billing and reimbursement of care</p> Signup and view all the answers

    What is a critical aspect of documentation in healthcare?

    <p>Documenting patient care in a timely manner</p> Signup and view all the answers

    What is a potential consequence of incomplete or illegible records?

    <p>Malpractice claims</p> Signup and view all the answers

    What is the primary function of the healthcare record?

    <p>Providing a legal record of care</p> Signup and view all the answers

    Why is accurate documentation important in healthcare?

    <p>To reduce liability for healthcare providers</p> Signup and view all the answers

    What is a benefit of documenting patient care in a timely manner?

    <p>Reduced liability for healthcare providers</p> Signup and view all the answers

    What is a potential consequence of failing to document nursing actions?

    <p>Malpractice claims</p> Signup and view all the answers

    What is a primary responsibility of healthcare providers?

    <p>Documenting patient care</p> Signup and view all the answers

    What is a key feature of the healthcare record?

    <p>It is a confidential and permanent document</p> Signup and view all the answers

    Why is the healthcare record an important means of communication?

    <p>It provides a clear and accurate account of patient care</p> Signup and view all the answers

    What is the primary purpose of accurate documentation of nursing services provided?

    <p>To determine payment or reimbursement for health care services</p> Signup and view all the answers

    What is the role of a quality improvement (QI) nurse in auditing health records?

    <p>To determine whether nurses consistently and accurately document implementation of fall precautions</p> Signup and view all the answers

    What is the benefit of reading the record of a patient for whom you are assigned to care?

    <p>To learn the nature of a patient's condition and response to treatment</p> Signup and view all the answers

    What is the purpose of de-identified data obtained from health records?

    <p>To support research studies on health care problems</p> Signup and view all the answers

    What is the requirement for using an electronic health record system (EHRS) according to the concept of meaningful use?

    <p>All of the above</p> Signup and view all the answers

    What is the primary difference between an electronic health record (EHR) and an electronic medical record (EMR)?

    <p>EHR is for a patient's lifetime record, while EMR is for an individual visit</p> Signup and view all the answers

    What is a unique feature of an electronic health record (EHR)?

    <p>It integrates all patient information into one record, regardless of the number of times a patient enters a health care system</p> Signup and view all the answers

    What is the purpose of an institutional review board (IRB) in a health care agency or hospital?

    <p>To approve research studies on health care problems</p> Signup and view all the answers

    What is the role of audits of health records in health care?

    <p>To offer information on recurrent health care problems and specific patient incidents</p> Signup and view all the answers

    What is the benefit of analyzing de-identified data obtained from health records?

    <p>To contribute to evidence-based nursing practice and high-quality health care</p> Signup and view all the answers

    What is one of the key advantages of an EHR for nursing?

    <p>Comparing current clinical data about a patient with data from previous health care encounters</p> Signup and view all the answers

    Under HIPAA, what is required to eliminate barriers that potentially delay access to care?

    <p>Notifying patients of privacy policies and obtaining written acknowledgment</p> Signup and view all the answers

    When can nurses use health records for data gathering, research, or continuing education?

    <p>As long as records are used as specified and permission is granted from an institutional review board</p> Signup and view all the answers

    What is the responsibility of all persons working in healthcare under HIPAA?

    <p>Ensuring appropriate access to and confidentiality of personal health information</p> Signup and view all the answers

    What is a firewall in a computer information system?

    <p>A combination of hardware and software that protects private network resources from outside hackers</p> Signup and view all the answers

    What is essential to safeguard when using a health care agency computer system?

    <p>Safeguarding any information that is printed from the record or extracted for report purposes</p> Signup and view all the answers

    What is a characteristic of strong passwords?

    <p>Using combinations of letters, numbers, and symbols that are difficult to guess</p> Signup and view all the answers

    What is required when using a health care agency computer system?

    <p>Frequently changing personal passwords to prevent unauthorized persons from tampering with records</p> Signup and view all the answers

    What is individually identifiable information relating to an individual's past, present, or future health status?

    <p>Personal health information</p> Signup and view all the answers

    Why is it essential to maintain patient confidentiality?

    <p>To ensure appropriate access to and confidentiality of personal health information</p> Signup and view all the answers

    What is the primary purpose of acuity rating systems in healthcare?

    <p>To determine the hours of care and number of staff required for a given group of patients</p> Signup and view all the answers

    What is the focus of Health Information Technology (HIT)?

    <p>The patient and the process of care</p> Signup and view all the answers

    What is a clinical information system (CIS)?

    <p>A computerized database management system used to access patient data needed to plan, implement, and evaluate care</p> Signup and view all the answers

    What is the benefit of using a computerized provider order entry (CPOE) system?

    <p>It improves productivity and cost-effectiveness in the communication and implementation of health care provider orders</p> Signup and view all the answers

    What is the acuity level of a patient who requires frequent monitoring and extensive care after surgery?

    <p>3</p> Signup and view all the answers

    What is the purpose of a health care information system (HIS)?

    <p>To make the entry and communication of data and information more efficient</p> Signup and view all the answers

    What is the role of documentation in long-term care facilities?

    <p>To support an interprofessional approach to the assessment and planning process for all patients</p> Signup and view all the answers

    What is an incident report in a patient's health care record used for?

    <p>To make the incident report part of the health care record and therefore admissible for attorney review</p> Signup and view all the answers

    What is the role of a clinical information system (CIS) in healthcare?

    <p>To access patient data needed to plan, implement, and evaluate care</p> Signup and view all the answers

    What is the benefit of accurate acuity ratings in healthcare?

    <p>They justify the number and qualifications of staff needed to safely care for patients</p> Signup and view all the answers

    What advantage do NCISs offer to nurses in practice?

    <p>Better access to information</p> Signup and view all the answers

    What is the purpose of a CDSS?

    <p>To aid in clinical decision making</p> Signup and view all the answers

    What is nursing informatics?

    <p>A specialty that integrates nursing science, computer science, and information science</p> Signup and view all the answers

    What is the benefit of NCISs for accrediting agencies?

    <p>Adherence to requirements of accrediting agencies</p> Signup and view all the answers

    What type of design does an NCIS have?

    <p>Nursing process design and critical pathway design</p> Signup and view all the answers

    What is the purpose of a protocol or critical pathway design in an NCIS?

    <p>To facilitate interprofessional management of information</p> Signup and view all the answers

    What is the benefit of a well-designed NCIS?

    <p>Enhanced quality of documentation</p> Signup and view all the answers

    What is the primary purpose of flow sheets in the EHR?

    <p>To quickly and easily enter patient assessment data</p> Signup and view all the answers

    What is the purpose of an effective CDSS?

    <p>To notify health care providers of patient allergies</p> Signup and view all the answers

    What is the philosophy behind charting by exception (CBE)?

    <p>All standards for normal assessment findings are met unless otherwise documented</p> Signup and view all the answers

    What is the purpose of a nursing history form?

    <p>To guide the nurse through a comprehensive assessment to identify relevant nursing diagnoses or problems</p> Signup and view all the answers

    What type of information can be seen in flow sheets?

    <p>Patient trends over time</p> Signup and view all the answers

    Where can a nurse document additional detailed information about a patient's status and response to an activity?

    <p>In the narrative progress note or within the flow sheet</p> Signup and view all the answers

    What is the purpose of narrative progress notes?

    <p>To monitor progress made toward resolving a patient's problems</p> Signup and view all the answers

    What is the benefit of using flow sheets in the EHR?

    <p>They provide current patient information accessible to all members of the health care team</p> Signup and view all the answers

    What is the role of well-designed flow sheets in the EHR?

    <p>They are a key part of a good exception-based documentation system</p> Signup and view all the answers

    What is the primary purpose of completing a patient care summary document at the beginning and/or end of each shift?

    <p>To organize care and give a hand-off report</p> Signup and view all the answers

    What is the benefit of using standardized care plans?

    <p>They improve continuity of care among professional nurses</p> Signup and view all the answers

    What is included in a discharge summary document?

    <p>Medications, diet, community resources, and follow-up care</p> Signup and view all the answers

    Why should telephone orders and verbal orders be used only when absolutely necessary?

    <p>Because they are error-prone and may be misheard</p> Signup and view all the answers

    What information should be included when documenting a telephone order or verbal order?

    <p>The date and time of the call, the number called, and who made the call</p> Signup and view all the answers

    What is the purpose of incident reports?

    <p>To document an objective description of what happened and the follow-up actions taken</p> Signup and view all the answers

    What should be done when documenting an incident report?

    <p>Evaluate and document the patient's response to the incident in the health care record</p> Signup and view all the answers

    Why is it important to involve the patient and family in the discharge planning process?

    <p>To ensure that they have the necessary information and resources to return home or move to the next level of care</p> Signup and view all the answers

    What is the purpose of interprofessional discharge planning?

    <p>To develop a comprehensive plan for a safe discharge</p> Signup and view all the answers

    What is the benefit of documenting the patient's care in a timely manner?

    <p>It ensures that the patient's care is well-coordinated and continuous</p> Signup and view all the answers

    What is the primary purpose of documentation in the home health care setting?

    <p>To justify reimbursement from Medicare, Medicaid, or private insurance companies</p> Signup and view all the answers

    Which data sets do nurses use to document clinical assessments and care provided in the home care setting?

    <p>OASIS and Omaha system</p> Signup and view all the answers

    What is the role of documentation in the home health care setting?

    <p>To provide quality control and justify reimbursement</p> Signup and view all the answers

    Why is documentation necessary in the home health care setting?

    <p>To justify reimbursement from Medicare, Medicaid, or private insurance companies</p> Signup and view all the answers

    What is the relationship between documentation and reimbursement in the home health care setting?

    <p>Documentation is necessary for reimbursement</p> Signup and view all the answers

    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

    Home Health Care Documentation

    • Medicare has specific guidelines to establish eligibility for home care reimbursement
    • Documentation serves as quality control and justification for reimbursement from Medicare, Medicaid, or private insurance companies
    • Nurses use two primary data sets for documentation in home care settings:
      • OASIS (Outcome and Assessment Information Set)
      • Omaha system

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    Description

    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.

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