NUR 231 EXAM 3 QUESTIONS WITH VERIFIED
ANSWERS GRADED A+
documentation
the written or electronic legal record of all pertinent interactions with the patient: assessing,
diagnosing, planning, implementing, and evaluting
patient record
- a compilation of a patient's health information (PHI)
- the only permanent legal document that details the nurse's interactions with the patient
breaches in confidentiality
- discussing patient information in any public area
- leaving patient medical information in a public area
- leaving a computer unattended in an accessible area with medical record information unsecured
- failing to log off a computer terminal
- sharing or exposing passwords
- copying or providing data, for yourself, coworkers, or any other party, except as required to fulfill job
responsibilities
- improperly accessing, reviewing, or releasing a patient record to use information in a personal
relationship, for the intent of giving or selling information to the media, bringing harm to the
organization or people associated with it
content (documentation guidelines)
- enter information in a complete, accurate, concise, current, and factual manner
- make sure your documentation reflects the nursing process and your professional responsibilities
- record patient findings rather than your interpretation of these findings
- avoid words such as "good," "average," "normal," or "sufficient" which may mean different things to
different readers
- avoid generalizations such as "seems comfortable today"
- note problems as they occur in an orderly, sequential manner; record the nursing intervention and
the patient's response; update problems or delete as appropriate
- record precautions or preventive measures used
- document in a legally prudent manner, know and adhere to professional standards and
facility/institutional policy for documentation
- document the nursing response to questionable medical orders or treatment
- document objectively; avoid slang terms, stereotypes, or derogatory terms when charting
- document quotes from the patient and behaviors
- refrain from copying and pasting notes in an EHR, because the data may be outdated or inaccurate
timing (documentation guidelines)
- document in a timely manner
- if you forget to document something, record it as soon as you can, following the procedures for
making late entries
- indicate in each entry the date and both the time the entry was written and the time of pertinent
observations and interventions
- most facilities use military time to avoid confusion between am and pm times
- document nursing interventions as closely as possible to the time of their execution
- never document interventions before carrying them out
format (documentation guidelines)
- check to make sure you have the correct chart before writing
,- record on the proper form or screen as designated by facility policy
- with paper charts, print or write legibly in dark ink to ensure permanence
- use correct grammar and spelling, use standard terminology, only commonly accepted terms and
abbreviations, and symbols
- date and time each entry
- record nursing interventions chronologically on consecutive lines
accountability (documentation guidelines)
- sign your first initial, last name, and title to each entry
- do not use dittos, erasures, or correcting fluids, draw a single line through an incorrect entry and
write "error"
- identify each page of the record with the pt's name and identification number
- recognize that the patient record is permanent, follow facility policy pertaining to the color of ink
and the type of pen or ink to be used, ensure that the pt record is complete before sending it to
medical records
confidentiality (documentation guidelines)
- pts have a moral and legal right to expect that the information contained in their pt health record
will be kept private
- be familiar with facility policies
- actual pt names and other identifiers should not be used in written or oral student reports
patient rights
- see and copy their health record
- update their health record
- get a list of the disclosures that a health care institution has made independent of disclosures made
for the purposes of treatment, payment, and health care operations
- request a restriction on certain uses or disclosures
- choose how to receive health information
electronic health records
- computer based
- data can be distributed among many caregivers in a standardized format, allowing them to compare
and uniformly evaluate patient progress easily
- computerized outcome information can aid in comparing the progress of groups of patients with
similar diagnoses
- help reduce medical errors and adverse events
- enable better documentation and file organization
- provide patients with information that assists their adherence to medication regimens and
scheduled appointments
- assist health care providers track their treatment protocols
- allow pt information to flow between and within health care facilities and practices can enhance
primary care provider decision making and improve care coordination
computerized provider order entry
this section of the EHR is for the orders written by the health care provider that are deemed necessary
for the patient such as required lab tests, procedures, medications, and treatments, this section was
formerly known as the section of the paper medical record known as "physician's orders"
clinical decision support (CDS)
, - includes academic information, medical logic, and analytic programs built into the EHR that can
assist the health care provider make diagnoses and clinical decisions about patient care
- examples include patient genetic information, past pt health history data that influences current
health problem, potential drug-drug interactions, pharmacogenomic information applicable to the pt,
interpretation of abnormal lab results
health information exchange
- allows physicians, NPs, PAs, RNs, pharmacists, other health care providers, and pts to appropriately
access and securely share a pt's vital medical information electronically, improving the speed, quality,
safety, and cost of pt care
electronic database
a collection of data that allows easy searching and easy retrieval of similar pieces of data from many
records
medication administration record
- used to electronically track and record administration of pt medications
- includes the pt's name, each medication's name, dose, frequency, and route
personal health records
- are patient records of their own medical data and health history
- can be interfaced with applications within EHRs and are used by most large facilities
- are allowing patients to take a more active role in managing their health care by documenting their
past health history and current health care goals
- this communication feature has enhanced patient-centered care provided by health care providers
source oriented record
- a paper format in which each health care group keeps data on its own separate form
- sections of the record are designated for nurses, health care providers, laboratory, x-ray personnel,
and so on
- notations are entered chronologically, with the most recent entry being nearest to the front
progress notes
notes written to inform caregivers of the progress a patient is making toward achieving expected
outcomes
problem oriented medical record
- organized around a patient's problems rather than around sources of information
- all health care professionals record information on the same forms
- the advantages of this type of record are that the entire health care team works together in
identifying a master list of patient problems and contributes collaboratively to the care plan
focus charting
- purpose is to bring the focus of care back to the patient and the patient's concerns
- the advantage is the holistic emphasis on the patient and the patient's priorities
flow sheets
documentation tools used to efficiently record routine aspects of nursing care
ANSWERS GRADED A+
documentation
the written or electronic legal record of all pertinent interactions with the patient: assessing,
diagnosing, planning, implementing, and evaluting
patient record
- a compilation of a patient's health information (PHI)
- the only permanent legal document that details the nurse's interactions with the patient
breaches in confidentiality
- discussing patient information in any public area
- leaving patient medical information in a public area
- leaving a computer unattended in an accessible area with medical record information unsecured
- failing to log off a computer terminal
- sharing or exposing passwords
- copying or providing data, for yourself, coworkers, or any other party, except as required to fulfill job
responsibilities
- improperly accessing, reviewing, or releasing a patient record to use information in a personal
relationship, for the intent of giving or selling information to the media, bringing harm to the
organization or people associated with it
content (documentation guidelines)
- enter information in a complete, accurate, concise, current, and factual manner
- make sure your documentation reflects the nursing process and your professional responsibilities
- record patient findings rather than your interpretation of these findings
- avoid words such as "good," "average," "normal," or "sufficient" which may mean different things to
different readers
- avoid generalizations such as "seems comfortable today"
- note problems as they occur in an orderly, sequential manner; record the nursing intervention and
the patient's response; update problems or delete as appropriate
- record precautions or preventive measures used
- document in a legally prudent manner, know and adhere to professional standards and
facility/institutional policy for documentation
- document the nursing response to questionable medical orders or treatment
- document objectively; avoid slang terms, stereotypes, or derogatory terms when charting
- document quotes from the patient and behaviors
- refrain from copying and pasting notes in an EHR, because the data may be outdated or inaccurate
timing (documentation guidelines)
- document in a timely manner
- if you forget to document something, record it as soon as you can, following the procedures for
making late entries
- indicate in each entry the date and both the time the entry was written and the time of pertinent
observations and interventions
- most facilities use military time to avoid confusion between am and pm times
- document nursing interventions as closely as possible to the time of their execution
- never document interventions before carrying them out
format (documentation guidelines)
- check to make sure you have the correct chart before writing
,- record on the proper form or screen as designated by facility policy
- with paper charts, print or write legibly in dark ink to ensure permanence
- use correct grammar and spelling, use standard terminology, only commonly accepted terms and
abbreviations, and symbols
- date and time each entry
- record nursing interventions chronologically on consecutive lines
accountability (documentation guidelines)
- sign your first initial, last name, and title to each entry
- do not use dittos, erasures, or correcting fluids, draw a single line through an incorrect entry and
write "error"
- identify each page of the record with the pt's name and identification number
- recognize that the patient record is permanent, follow facility policy pertaining to the color of ink
and the type of pen or ink to be used, ensure that the pt record is complete before sending it to
medical records
confidentiality (documentation guidelines)
- pts have a moral and legal right to expect that the information contained in their pt health record
will be kept private
- be familiar with facility policies
- actual pt names and other identifiers should not be used in written or oral student reports
patient rights
- see and copy their health record
- update their health record
- get a list of the disclosures that a health care institution has made independent of disclosures made
for the purposes of treatment, payment, and health care operations
- request a restriction on certain uses or disclosures
- choose how to receive health information
electronic health records
- computer based
- data can be distributed among many caregivers in a standardized format, allowing them to compare
and uniformly evaluate patient progress easily
- computerized outcome information can aid in comparing the progress of groups of patients with
similar diagnoses
- help reduce medical errors and adverse events
- enable better documentation and file organization
- provide patients with information that assists their adherence to medication regimens and
scheduled appointments
- assist health care providers track their treatment protocols
- allow pt information to flow between and within health care facilities and practices can enhance
primary care provider decision making and improve care coordination
computerized provider order entry
this section of the EHR is for the orders written by the health care provider that are deemed necessary
for the patient such as required lab tests, procedures, medications, and treatments, this section was
formerly known as the section of the paper medical record known as "physician's orders"
clinical decision support (CDS)
, - includes academic information, medical logic, and analytic programs built into the EHR that can
assist the health care provider make diagnoses and clinical decisions about patient care
- examples include patient genetic information, past pt health history data that influences current
health problem, potential drug-drug interactions, pharmacogenomic information applicable to the pt,
interpretation of abnormal lab results
health information exchange
- allows physicians, NPs, PAs, RNs, pharmacists, other health care providers, and pts to appropriately
access and securely share a pt's vital medical information electronically, improving the speed, quality,
safety, and cost of pt care
electronic database
a collection of data that allows easy searching and easy retrieval of similar pieces of data from many
records
medication administration record
- used to electronically track and record administration of pt medications
- includes the pt's name, each medication's name, dose, frequency, and route
personal health records
- are patient records of their own medical data and health history
- can be interfaced with applications within EHRs and are used by most large facilities
- are allowing patients to take a more active role in managing their health care by documenting their
past health history and current health care goals
- this communication feature has enhanced patient-centered care provided by health care providers
source oriented record
- a paper format in which each health care group keeps data on its own separate form
- sections of the record are designated for nurses, health care providers, laboratory, x-ray personnel,
and so on
- notations are entered chronologically, with the most recent entry being nearest to the front
progress notes
notes written to inform caregivers of the progress a patient is making toward achieving expected
outcomes
problem oriented medical record
- organized around a patient's problems rather than around sources of information
- all health care professionals record information on the same forms
- the advantages of this type of record are that the entire health care team works together in
identifying a master list of patient problems and contributes collaboratively to the care plan
focus charting
- purpose is to bring the focus of care back to the patient and the patient's concerns
- the advantage is the holistic emphasis on the patient and the patient's priorities
flow sheets
documentation tools used to efficiently record routine aspects of nursing care
