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Questions and Answers
What is the primary factor that determines a patient's acuity level?
What is the primary factor that determines a patient's acuity level?
Which organization has specific guidelines for documentation to establish eligibility for home care reimbursement?
Which organization has specific guidelines for documentation to establish eligibility for home care reimbursement?
What is the primary purpose of documentation in healthcare?
What is the primary purpose of documentation in healthcare?
What is the main purpose of documentation in the health care setting?
What is the main purpose of documentation in the health care setting?
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What is the primary focus of case management models?
What is the primary focus of case management models?
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What is the term for an individual's lifetime computerized record?
What is the term for an individual's lifetime computerized record?
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What are critical pathways?
What are critical pathways?
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What is the purpose of an acuity rating system in healthcare?
What is the purpose of an acuity rating system in healthcare?
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What is the term for protecting sensitive patient information?
What is the term for protecting sensitive patient information?
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What is the primary purpose of health care information technology (HIT)?
What is the primary purpose of health care information technology (HIT)?
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What is a clinical information system (CIS)?
What is a clinical information system (CIS)?
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What is the purpose of maintaining privacy, confidentiality, and security of the health care record?
What is the purpose of maintaining privacy, confidentiality, and security of the health care record?
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What is the primary advantage of using nursing clinical information systems (NCIS)?
What is the primary advantage of using nursing clinical information systems (NCIS)?
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What is the term for a written account of patient data, clinical interventions, and patient responses?
What is the term for a written account of patient data, clinical interventions, and patient responses?
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What is the primary focus of nursing informatics?
What is the primary focus of nursing informatics?
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What is the purpose of an admission nursing history form?
What is the purpose of an admission nursing history form?
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What is the term for the process of needed for quality and performance improvement?
What is the term for the process of needed for quality and performance improvement?
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What is the purpose of documenting telephone calls and verbal orders?
What is the purpose of documenting telephone calls and verbal orders?
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What is the term for the record for an individual health care visit?
What is the term for the record for an individual health care visit?
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What is the primary basis for determining a patient's acuity level over a 24-hour period?
What is the primary basis for determining a patient's acuity level over a 24-hour period?
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Which of the following organizations governs documentation in the long-term health care setting?
Which of the following organizations governs documentation in the long-term health care setting?
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What is the primary purpose of OASIS and Omaha system in home health care documentation?
What is the primary purpose of OASIS and Omaha system in home health care documentation?
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What is the term for unexpected outcomes, unmet goals, and interventions not specified within a critical pathway?
What is the term for unexpected outcomes, unmet goals, and interventions not specified within a critical pathway?
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What is the primary advantage of using computerized provider order entry (CPOE) in clinical information systems?
What is the primary advantage of using computerized provider order entry (CPOE) in clinical information systems?
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What is the primary purpose of nursing clinical information systems (NCIS)?
What is the primary purpose of nursing clinical information systems (NCIS)?
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What is the primary focus of clinical decision support systems (CDSS)?
What is the primary focus of clinical decision support systems (CDSS)?
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What is the primary role of nursing informatics in healthcare?
What is the primary role of nursing informatics in healthcare?
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What is the primary purpose of informatics competencies for nursing graduates?
What is the primary purpose of informatics competencies for nursing graduates?
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What is the primary focus of health care information technology (HIT)?
What is the primary focus of health care information technology (HIT)?
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Which of the following is NOT a purpose of the health care record?
Which of the following is NOT a purpose of the health care record?
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What is the primary difference between an Electronic Health Record (EHR) and an Electronic Medical Record (EMR)?
What is the primary difference between an Electronic Health Record (EHR) and an Electronic Medical Record (EMR)?
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What is the primary purpose of maintaining privacy, confidentiality, and security of the health care record?
What is the primary purpose of maintaining privacy, confidentiality, and security of the health care record?
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Which of the following is a standard for quality nursing documentation?
Which of the following is a standard for quality nursing documentation?
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What is the primary purpose of an acuity rating system?
What is the primary purpose of an acuity rating system?
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What is the purpose of documenting patient assessment data?
What is the purpose of documenting patient assessment data?
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Which of the following is a method of documentation?
Which of the following is a method of documentation?
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What is the purpose of documenting communication with providers and unique events?
What is the purpose of documenting communication with providers and unique events?
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Which of the following is NOT a purpose of the electronic health record system (EHRS)?
Which of the following is NOT a purpose of the electronic health record system (EHRS)?
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What is the purpose of standards and guidelines for quality nursing documentation?
What is the purpose of standards and guidelines for quality nursing documentation?
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Study Notes
Documentation and Informatics
Purposes of the Health Care Record
- Facilitates interprofessional communication
- Provides a legal record of care
- Provides justification for financial billing and reimbursement of care
- Supports the process of quality and performance improvement
- Serves as a resource for education and research
Interprofessional Communication Within the Medical Record
- Legal documentation
- Reimbursement (diagnosis-related groups)
- Auditing and monitoring
- Education
- Research
- Shift to electronic documentation (electronic health record system (EHRS) and electronic health record (EHR))
Maintaining Privacy, Confidentiality, and Security
- Protected health information (PHI)
- Mechanisms: firewall, password, and procedures for handling and disposing of information
- Policies for the use of fax machines
Standards and Guidelines for Quality Nursing Documentation
- Factual
- Accurate
- Appropriate use of abbreviations
- Current
- Organized
- Complete
Methods of Documentation
- Documentation of patient assessment data: flow sheets, progress notes, charting by exception
Common Record-Keeping Forms within the Electronic Health Record
- Admission nursing history form
- Patient care summary
- Care plans
- Discharge summary forms
Documenting Communication with Providers and Unique Events
- Telephone calls
- Telephone and verbal orders
- Incidence or occurrence reports
Acuity Rating Systems
- Used to determine hours of care and number of staff required for a group of patients
- Based on the type and number of nursing interventions required by a patient over a 24-hour period
Documentation in Long-Term and Home Health Care Settings
- Governed by individual state regulations, The Joint Commission (TJC), and Centers for Medicare and Medicaid Services (CMS)
- Medicare has specific guidelines to establish eligibility for home care reimbursement
- Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance companies
- OASIS and Omaha system data sets are used to document clinical assessments and care provided in the home care setting
Case Management and Use of Critical Pathways
- Case management model incorporates an interprofessional approach to delivery and documentation of patient care
- Critical pathways identify patient problems, key interventions, and expected outcomes within an established time frame
- Variances: unexpected outcomes, unmet goals, and interventions not specified within a critical pathway
Informatics and Information Management in Health Care
- Health care information technology (HIT) enhances quality and efficiency of care
- Health care information system (HIS) includes clinical information system (CIS) and administrative information system
- Clinical information system (CIS) example: computerized provider order entry (CPOE)
- Nursing clinical information systems (NCIS) have two designs: nursing model and critical pathway
- Clinical decision support systems (CDSS) aid and support clinical decision making
- Nursing informatics is a specialty area of practice that integrates nursing science, computer science, and information science
Documentation and Informatics
Purposes of the Health Care Record
- Facilitates interprofessional communication
- Provides a legal record of care
- Provides justification for financial billing and reimbursement of care
- Supports the process of quality and performance improvement
- Serves as a resource for education and research
Interprofessional Communication Within the Medical Record
- Legal documentation
- Reimbursement (diagnosis-related groups)
- Auditing and monitoring
- Education
- Research
- Shift to electronic documentation (electronic health record system (EHRS) and electronic health record (EHR))
Maintaining Privacy, Confidentiality, and Security
- Protected health information (PHI)
- Mechanisms: firewall, password, and procedures for handling and disposing of information
- Policies for the use of fax machines
Standards and Guidelines for Quality Nursing Documentation
- Factual
- Accurate
- Appropriate use of abbreviations
- Current
- Organized
- Complete
Methods of Documentation
- Documentation of patient assessment data: flow sheets, progress notes, charting by exception
Common Record-Keeping Forms within the Electronic Health Record
- Admission nursing history form
- Patient care summary
- Care plans
- Discharge summary forms
Documenting Communication with Providers and Unique Events
- Telephone calls
- Telephone and verbal orders
- Incidence or occurrence reports
Acuity Rating Systems
- Used to determine hours of care and number of staff required for a group of patients
- Based on the type and number of nursing interventions required by a patient over a 24-hour period
Documentation in Long-Term and Home Health Care Settings
- Governed by individual state regulations, The Joint Commission (TJC), and Centers for Medicare and Medicaid Services (CMS)
- Medicare has specific guidelines to establish eligibility for home care reimbursement
- Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance companies
- OASIS and Omaha system data sets are used to document clinical assessments and care provided in the home care setting
Case Management and Use of Critical Pathways
- Case management model incorporates an interprofessional approach to delivery and documentation of patient care
- Critical pathways identify patient problems, key interventions, and expected outcomes within an established time frame
- Variances: unexpected outcomes, unmet goals, and interventions not specified within a critical pathway
Informatics and Information Management in Health Care
- Health care information technology (HIT) enhances quality and efficiency of care
- Health care information system (HIS) includes clinical information system (CIS) and administrative information system
- Clinical information system (CIS) example: computerized provider order entry (CPOE)
- Nursing clinical information systems (NCIS) have two designs: nursing model and critical pathway
- Clinical decision support systems (CDSS) aid and support clinical decision making
- Nursing informatics is a specialty area of practice that integrates nursing science, computer science, and information science
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Description
This quiz covers the fundamentals of informatics and documentation in nursing, including documentation as a key communication strategy and its importance in healthcare.
