ATI COMPREHENSIVE PREDICTOR EXAM

ATI COMPREHENSIVE PREDICTOR EXAM 1. A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per a. standing order. Cooperative, patient coughed and deep breathed using a pillow as a b. splint. Stated, “felt better.” Finally, patient had no complaints. Breathing without difficulty. Sitting up in bed watching TV. Had a c. good day. Status unchanged. Remains stable with no abnormal findings. d. Checked every 2 hours. ANS: A Accurately documenting services provided, including the supplies and equipment used in a patient’s care, clarifies the type of treatment a patient received. This documentation also supports accurate and timely reimbursement to a health care agency and/or patient. None of the other options had equipment or supplies listed. Avoid using generalized, empty phrases such as “status unchanged” or “had good day.” Do not enter personal opinions—stating that the patient is cooperative is a personal opinion and should be avoided. “Finally, patient had no complaints” is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care. 2. A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session? Home health, long-term care, and hospital nurses’ documentation can a. affect reimbursement for health care. A clinical information system must be installed by 2014 to obtain b. health care reimbursement. c. A “near miss” helps determine reimbursement issues for health care. d. HIPAA is the basis for establishing reimbursement for health care. ANS: A Nurses’ documentation practices in home health, long-term care, and hospitals can determine reimbursement for health care. A “near miss” is an incident where no property was damaged and no patient or personnel were injured, but given a slight shift in time or position, damage or injury could have easily occurred. A clinical information system (CIS) does not have to be installed by 2014 to obtain reimbursement. CIS programs include monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems. Diagnosis- related groups (DRGs) are the basis for establishing reimbursement for patient care, not HIPAA. Legislation to protect patient privacy regarding health information is the Health Insurance Portability and Accountability Act (HIPAA). 3. A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe? a. Varied clinical databases b. Reduced errors of omission c. Increased hospital costs d. More time to read charts ANS: B Advantages associated with the nursing information system include reduced errors of omission; better access to information (not more time to read charts); enhanced quality of documentation; reduced, not increased, hospital costs; increased nurse job satisfaction; compliance with requirements of accrediting agencies (e.g., TJC); and development of a common, not varied, clinical database. MULTIPLE RESPONSE 1. Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.) Writes the patient’s room number and date of birth on a paper for a. school Prints/copies material from the patient’s health record for a graded b. care plan Reviews assigned patient’s record and another unassigned patient’s c. record d. Gives a change-of-shift report to the oncoming nurse about the patient e. Reads the progress notes of assigned patient’s record f. Discusses patient care with the hospital volunteer ANS: D, E When you are a student in a clinical setting, confidentiality and compliance with HIPAA are part of professional practice. Reading the progress notes of an assigned patient’s record and giving a change-of-shift report to the oncoming nurse about the patient are behaviors that follow HIPAA and confidentiality guidelines. Do not share information with other patients or health care team members who are not caring for a patient. Not only is it unethical to view medical records of other patients, but breaches of confidentiality lead to disciplinary action by employers and dismissal from work or nursing school. To protect patient confidentiality, ensure that written materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information), and never print material from an electronic health record for personal use. 2. 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. Communication b. Legal documentation c. Reimbursement d. Nursing process e. Research f. Education ANS: A, B, C, E, F A patient’s record is a valuable source of data for all members of the health care team. Its purposes include interdisciplinary communication, legal documentation, financial billing (reimbursement), education, research, and auditing/monitoring. Nursing process is a way of thinking and performing nursing care; it is not a purpose of a health care record. 3. A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.) a. Bypass the firewall. b. Implement an automatic sign-off. c. Create a password with just letters. d. Use a programmed speed-dial key when faxing. e. Impose disciplinary actions for inappropriate access. f. Shred papers containing personal health information (PHI). ANS: B, D, E, F When faxing, use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. An automatic sign-off is a safety mechanism that logs a user off the computer system after a specified period of inactivity. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information. All papers containing PHI (e.g., Social Security number, date of birth or age, patient’s name or address) must be destroyed immediately after you use or fax them. Most agencies have shredders or locked receptacles for shredding and incineration. Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. A firewall is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information and should not be bypassed.