NURS 231 Exam 3 Questions With Verified Answers Graded A+ 2024/2025
This is the written or electronic legal record of all pertinent interactions with the patient?
That would be documentation.
What 5 things does documentation require?
assessing, diagnosing, planning, implementing, and evalu...
NURS 231 Exam 3 Questions With Verified
Answers Graded A+ 2024/2025
This is the written or electronic legal record of all pertinent interactions with the patient?
That would be documentation.
What 5 things does documentation require?
assessing, diagnosing, planning, implementing, and evaluating.
A repeated phrase by nurses regarding documentation
"if it wasn't charted, it wasn't done"
a compilation of patient health information is a
patient record.
This committee specifics that nursing care data related to the patients assessments, nursing diagnoses
or patient needs, nursing interventions, and patient outcomes are permanently integrated into the
patient record.
the joint commission
what is the only permanent legal document that details the nurses interactions with the patient?
The patient record
what was the purpose of the ANA's principles for nursing documentation?
Essentially helps nurses document better and faster.
effective documentation is accessible, accurate, relevant, and consistent; auditable, clear, concise,
and complete; legible/readable; thoughtful; timely, contemporaneous, and sequential; reflective of
the nursing process; and retrievable on a permanent basis in a nursing-specific manner. who decided
this standard?
The ANA
what information is considered confidential?
all information regarding the patient. This includes, any patient identifiers, reasons they are there,
assessments and treatments, information about past medical conditions.
what examples of breaches in confidentiality?
1. discussing patients in any public area.
2. leaving patient information in a public area.
3. leaving a computer open in a public area.
4. sharing or exposing passwords
5. copying data for yourself.
what are ways to prevent data breaches on computers?
1. make sure that screens do not face the public.
2. only send emails on safe wifi
3. request a copier for the unit that you are on and only using that copier.
,4. use a disposal container when destroying patient forms
5. use safe phones
6. verify the fax number before sending the information
7. do not use voice pagers
HIPPA states that
1. see and copy their health record.
2. update their health record.
3. 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.
4. request a restriction on certain uses or disclosures.
5. choose how to receive health information.
If a health institution wants to release patient health information (PHI) for purposes other than
treatment, payment, or routine health care operations, the patient must be asked to sign an
authorization
what are the 3 exceptions for patient health information to be shared without authorization
1. public health activities
2. law enforcement and judicial proceedings
3. deceased people
what is an incidental disclosure of PHI and examples?
Something that is a byproduct and cannot be stopped or used.... examples: sign-in sheets, confidential
conversation being overheard, white boards, X-ray boards, or calling names in a waiting room.
what is a rule when documenting so that everyone can understand what is being documented?
do not use abbrieviations
They should NEVER be used when communicating medical information?
This includes internal communications, telephone/verbal prescriptions, computer generated labels,
labels for drug storage bins, medication administration records, as well as pharmacy and prescriber
computer order entry screens
what is important to remember when delegating documentation?
their needs to be a clear indication on which things the UAP is documenting and the nurse is
documenting. A good rule is to only document what you did.
what is the purpose of a patient record?
For communication and for the people involved in that patients care to have resources on what is
going on with the patient.
communication allows health care professionals of different disciplines and shifts the opportunity to
see what is going on... it also does what
continues continuity of care
what are two things that may be in a patient record in relation to orders?
, diagnostic and therapeutic
if a nurse is unsure about an order in the EHR what should the nurse do?
check the original order
a verbal order must be given for a? and then what should the nurse do back?
should be given orally from a physician or nurse practitioner and the nurse should read it back for
clarification.
list the steps of a verbal order
1. record the orders in the patient's medical record with the letters VO (verbal order).
2. read back the order to verify accuracy of the order.
3. date and note the time the orders were issued
4. record VOs, the name of the physician or nurse practitioner who issued the orders, followed by the
nurse's own name and title.
A verbal order is sentenced to what
emergency situations
Patient's baseline and ongoing data and can see how the patient is responding to the treatment plan
from day to day is what?
is care planning
blank are legal documents that might be used as evidence in court proceedings
patient records
blank is the ability to exchange health information electronically can help you provide higher quality
and safer care for patients while creating tangible enhancements for your organization.
electronic health record
a personal database of information where sometimes patients scan in doctors' notes, test results, CT
images, and insurance information.
personal health record
blank allows patients can access their own records through a secure portal and see, for example, the
trend of their lab results over the last year, their immunization history, or due dates for screenings.
tethered PHR
blank allows physicians, nurse practitioners, physician assistants, nurses, pharmacists, other health
care providers, and patients to appropriately access and securely share a patient's vital medical
information electronically, improving the speed, quality, safety, and cost of patient care.
a health information exchange
blank is a paper format in which each health care group keeps data on its own separate form.
source-oriented record
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