Week 10 - Information & Documentation Quiz

A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse access?

A.Electronic medical record
B.Electronic health record
C.Electronic charting record
D.Electronic problem record
Click the card to flip 👆
1 / 10
Terms in this set (10)
A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse access?

A.Electronic medical record
B.Electronic health record
C.Electronic charting record
D.Electronic problem record
B.Electronic health record
A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient?

A.When the primary care provider writes the order
B.After the congestion is treated
C.Right before discharge
D.Upon admission
D.Upon admission
A patient is being discharged home. Which information should the nurse include?

A.Community resources
B.Standardized care plan
C.Acuity level
D.Signature for verbal order
A.Community resources
Which action will the nurse take when taking a telephone order?

A.Print out a copy of the order once entered into the electronic health record.
B.Ask that another registered nurse listen to the call over an extension line.
C.Read back the order as written to the health care provider for verification.
D.Verify that the health care provider will write the order within 24 hours.
C.Read back the order as written to the health care provider for verification.
A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?

A.12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.

B.12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back.

C.12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.

D.12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN.
C.12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.
A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up?

A.To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice.

B.A nurse needs to know how to find, evaluate, and use information effectively.

C.Nursing informatics is a recognized specialty area of nursing practice.

D.If a nurse has computer competency, the nurse is competent in informatics.
D.If a nurse has computer competency, the nurse is competent in informatics.
A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using?

A.Clinical decision support system
B.Computerized provider order entry system
C.Nursing process design
D.Critical pathway design
D.Critical pathway design
A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take?

A.Print out and review computer nursing notes at home.
B.Chart on the computer immediately after care is provided.
C.Use the same password all the time.
D.Share password with only one other staff member.
B.Chart on the computer immediately after care is provided.
Which entry will require follow-up by the nurse manager?0800 Patient states, "Fell out of bed." Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, "Did not pass out." Assisted back to bed. Nurse call system within reach. Bed monitor on. —Jane More, RN0810 Notified primary care provider of patient's status. New orders received. —Jane More, RN0815 Portable x-ray of L hip taken in room. States, "I feel fine." —Jane More, RN0830 Incident report completed and placed on chart. —Jane More, RN

A.0810
B.0815
C.0800
D.0830
D.0830
A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.)

A.Education
B.Nursing process
C.Legal documentation
D.Research
E.Communication
F.Reimbursement
A.Education
C.Legal documentation
D.Research
E.Communication
F.Reimbursement