Buy Documenting And Using Informatics

Buy Documenting And Using Informatics
Buy Documenting And Using Informatics
1. Which of the following documentation guidelines are
correct? Select all that apply.
a. Enter information in a complete, accurate, concise,
factual, and organized manner.
b. Use words such as “good,” “average,” “normal,” or
“sufficient” to communicate judgments about data.
c. Wait until the end of the shift to document nursing
interventions to ensure comprehensive charting.
d. Date and time each entry.
2. Which of the following documentation guidelines are
correct? Select all that apply.
a. Erase or use correcting fluid to completely delete
mistaken entries.
b. Document nursing interventions as closely as possible to the time of their execution.
c. Note problems as they occur in an orderly, sequential
d. Carefully document all the factors that compromise
patient safety and contribute to patient harm.
3. According to the Health Insurance Portability and
Accountability Act of 1996, patients have a right to
which of the following? Select all that apply.
a. To see and copy their health record
b. To update their health record
c. To get a list of the disclosures a healthcare institution
has made independent of disclosures made for the
purposes of treatment, payment, and healthcare
d. To request a restriction on certain uses or
e. To choose how to receive health information
Buy Documenting And Using Unformatics
a. The patient is a public figure and the local news
media are preparing a news report.
b. Data are needed for the tracking and notification of
disease outbreaks.
c. Child abuse and neglect are suspected.
d. Protected health information is needed to facilitate
organ donations.
5. A friend of yours calls you and asks if you are still
working at Memorial Hospital. You reply “yes.” He
tells you that his girlfriend’s father was just admitted
as a patient, and he wants you to find out how he is.
“Sue (his girlfriend) seems unusually worried about
her dad, but she won’t talk to me and I want to be able
to help her.” What is the best response you can make
to your friend?
a. “Listen, you shouldn’t be asking me to do this. I
could be fined big bucks or even lose my job for
disclosing this information.”
b. “Sorry, but I’m not able to give information about
patients to the public—even when my best friend
or a family member asks.”
c. “Because of the Health Insurance Portability and
Accountability Act, you shouldn’t be asking for this
information unless the patient has authorized you to
receive it! This could get you in trouble!”
d. “Why do you think Sue isn’t talking about her
6. Your patient has an order for an analgesic medication
to be given as needed. The correct abbreviation for
“as needed” is:
b. PMH
c. PRN
d. TPR
7. If you were looking for trends in a patient’s vital signs,
what form should you consult first?
a. Admission sheet
b. Admission nursing assessment
c. Activity flow sheet
d. Graphic sheet
8. This method of documentation uses the categories data,
action, and response (DAR) to facilitate charting.
a. Narrative notes
b. Focus charting
c. Charting by exception
d. Case management model
9. A resident called to see a patient in the middle of the
night is leaving the unit and remembers that he forgot
to write a new order for a pain medication you had
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