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The nurse contacts a provider about a change in a patient's condition
and receives several new orders for the patient over the phone. When
documenting telephone orders in the electronic health record, most
hospitals require a nurse to do which of the following?
1. Print out a copy of all telephone orders entered into the electronic
health record in order to keep them in personal records for legal
purposes.
,2. "Read back" all telephone orders to the provider over the phone to
verify all orders were heard, understood, and transcribed correctly
before entering the orders in the electronic health record.
3. Record telephone orders in the electronic health record, but wait to
implement the order(s) until they are electronically signed by the health
care provider who gave them.
4. Implement telephone order(s) immediately, but insist that the health
care provider come to the patient care unit to personally enter the order(
- ANSWER ✔✔2. "Read back" all telephone orders to the provider
over the phone to verify all orders were heard, understood, and
transcribed correctly before entering the orders in the electronic health
record.
The nurse is working in an agency that has recently implemented an
electronic health record. Which of the following are acceptable practices
for maintaining the security and confidentiality of electronic health record
information? (Select all that apply.)
1. Using a strong password and changing your password frequently
according to agency policy
,2. Allowing a temporary staff member to use your computer user name
and password to access the electronic record
3. Ensuring that work lists (and any other data that must be printed from
the electronic health record) are protected throughout the shift and
disposed of in a locked receptacle designated for documents that are to
be shredded when no longer needed
4. Ensuring that the patient information that is displayed on the computer
monitor that you are using is not visible to visitors and other health care
providers who are not involved in that patient's care
5. Remaining l - ANSWER ✔✔1. Using a strong password and
changing your password frequently according to agency policy
3. Ensuring that work lists (and any other data that must be printed from
the electronic health record) are protected throughout the shift and
disposed of in a locked receptacle designated for documents that are to
be shredded when no longer needed
4. Ensuring that the patient information that is displayed on the computer
monitor that you are using is not visible to visitors and other health care
providers who are not involved in that patient's care
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, When documenting an assessment of a patient's cardiac system in an
electronic health record, the nurse uses the computer mouse to select
the "WNL" statement to document the following findings: "Heart sounds
S1 & S2 auscultated. Heart rate between 80-100 beats per minute, and
regular. Denies chest pain." This is an example of using which of the
following documentation formats?
1. Focus charting incorporating "Data, Action & Response" (DAR)
2. Problem-intervention-evaluation (PIE)
3. Charting-by-exception (CBE)
4. Narrative documentation - ANSWER ✔✔3. Charting-by-exception
(CBE)
The nurse works at an agency where military time is used for
documentation, and needs to document that a patient was transported to
the operating room for an emergency procedure at 8 in the evening.
Point to the area on the clockface below that indicates 8 in the evening
in military time: - ANSWER ✔✔2000
The nurse who works at the local hospital is transferring a patient to an
acute rehabilitation center in another town. To complete the transfer,
information from the patient's electronic health record must be printed