Documentation ATI- FINAL

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A nurse is discussing computerized provider order entry (CPOE) systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE system?

"CPOE systems are associated with a slightly higher error rate."

"CPOE use does not include medication prescriptions."

"CPOE systems can increase the speed of care delivery." (correct)

"CPOE use is mandated by HIPAA under the Privacy Rule."

A nurse is talking with a client about their electronic health record (EHR) at the facility. Which of the following client statements indicates an understanding of EHRs?

"I will be able to track my health information." (correct)

"My personal information will be entered into a national database."

"I will have one EHR that will encompass the health care I've received over my lifetime."

"The goal of EHRs is to improve insurance coding."

A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include?

"Accessing the medical record of clients on units other than where you are assigned is allowed."

"There are large financial penalties for charting vital signs you obtain for another nurse's client."

"Personnel can be terminated for breaching a client's confidentiality." (correct)

"Once you have cared for a client, it is acceptable to look at their medical record on subsequent health care visits."

A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's office. Which of the following characteristics should the charge nurse plan to include? (Select all that apply.)

Reduces medical errors Signup and view all the answers

A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on The Joint Commission's Do Not Use List? (Select all that apply.)

MSO4 Signup and view all the answers

A nurse is reviewing documentation principles with a group of newly hired assistive personnel (AP). Which of the following information should the nurse include?

A nurse who delegates a task to an AP will review the charting for that task. Signup and view all the answers

A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include?

A problem-oriented medical record promotes information sharing among members of the interdisciplinary team. Signup and view all the answers

A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs?

The Institute of Medicine Signup and view all the answers

A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information?

"I can take a telephone prescription if a provider is directing a code for an unresponsive client." Signup and view all the answers

A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record?

Immunization data Signup and view all the answers

A charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data?

Rebound tenderness noted in RLQ of the abdomen. Signup and view all the answers

A nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries should the nurse identify as meeting the American Nurses Association (ANA) standards for documentation?

"The client vomited 240 mL of clear emesis but denies pain or nausea." Signup and view all the answers

A nurse manager is reviewing the documentation of four newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly?

Synthroid 100 mcg PO every morning ac Signup and view all the answers

A newly licensed nurse is orienting to a facility's documentation system. The facility requires staff to only document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods?

Charting by exception Signup and view all the answers

A nurse in a clinic is reviewing a client's prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed?

PRN Signup and view all the answers

A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following information should the nurse include as a benefit of electronic documentation?

The system alerts providers of possible actions that could cause client harm. Signup and view all the answers

A nurse is caring for a client following a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first? (Select all that apply.)

The admitting provider Signup and view all the answers

A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication?

By mouth Signup and view all the answers

A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include?

Facilities can establish their own rules for documentation methods. Signup and view all the answers

A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on exertion." Which of the following documentation formats describes this entry?

The "S" in SOAP Signup and view all the answers

Nurse Lesley locks the computer before she leaves to enter the client’s room with nurse Amy to adjust the heparin IV infusion. Which of the following is the correct rationale for this action?

To ensure the confidentiality of the information Signup and view all the answers

A nurse manager is discussing several different documentation systems with a group of newly licensed nurses. Drag the documentation methods to the appropriate definition.

PIE model = Simplified approach to documentation that utilizes flow sheets and progress notes but omits the plan of care; uses a nursing diagnosis to define the problem Problem-oriented medical records = used to create a comprehensive and organized approach among all members of the interdisciplinary team; includes assessment data, problem list, plan, and progress notes Focus chart = conters on specific health care problems and change in condition, client events and concerns; three items must be documented: data, action, and response (DAR) CBE = Documenting only unexpected findings based on standardized protocols; involves an assessment flowsheet with expected finding Signup and view all the answers

Match each abbreviation with its appropriate meaning.

Head of the bed = HOB At once = Stat presciption = Rx twice a day = BID Signup and view all the answers

In what situation is it acceptable to repeat back a verbal prescription without writing it down first?

In a sterile environment Signup and view all the answers

Which of the following actions is a step in receiving a verbal prescription?

Ask the provider to spell any words that are unclear Signup and view all the answers

The video shows a nurse verifying a prescription entered through a computerized provider order entry (CPOE) system. Which of the following are benefits of this form of prescription entry? (Select all that apply.)

Transcription errors are reduced Signup and view all the answers

Identify the sequence Monica should have used to obtain the verbal prescription from Delwin. (Drag the options into the correct order.)

Identify the clinet and relevant information = 1 trascribe the verbal prescription into the clients medical record = 2 sign the prescription or save it under the nurses own credentials = 4 read the prescription back to Delwin for confirmation = 3 Signup and view all the answers

Which of the following components of the client’s prescriptions require further clarification? (Select all that apply.)

Acetaminophen dose Signup and view all the answers