Adaptive quizzing chapter 3 questions with complete solutions.

Adaptive quizzing chapter 3 questions with complete solutions. A nurse receives a phone call about a patient whose paper chart cannot be found. What other document could be temporarily used in an effort to provide answers regarding the patient's condition, prescriptions, and treatments - correct answers.A Kardex or Rand In a health care facility, the patient's chart is created from the assessment findings of four different health care departments: primary health care providers, nurses, dieticians, and therapists. What is this kind of patient charting called? - correct answers.Source-oriented (narrative) charting The unit secretary informs the nurse that transportation is waiting to take a patient to surgery. Immediately before the patient is transported, what essential step should the nurse take? - correct answers.Chart the time the patient left and the method of transportation. A nurse is preparing to document patient care. What data are most important for the nurse to include? - correct answers.Time of care Patient's pain level Type of procedure performed Which protocol allows a patient to acquire access to his or her medical record - correct answers.Submitting a request in written form Which instructions should the student nurse follow in an effort to maintain patient confidentiality? - correct answers.Be vigilant in keeping documents in a safe place when in the clinical agency. Avoid leaving papers with patient identifiers in the nurses' station or conference rooms. Within the facility, guard at all times any documents with patient identifying information. The recording of patient care observations and responses in a descriptive format occurs in which charting format? - correct answers.Narrative charting A recent fire in a health care unit destroyed a few of the patient medical records. What content contained within a patient medical record might have been destroyed? - correct answers.Treatments Tests Orders A health care facility uses problem-oriented medical record (POMR) charting for documenting patient records. The new nurse manager feels that the word "problem" can carry negative connotations. Which charting method can the nurse manager suggest as an alternative, keeping in mind that minimal structural change can be made? - correct answers.Focus Charting Which action would serve as the best defense against legal claims associated with nursing care? - correct answers.Perform clear and precise documentation of goal-directed nursing care given What is considered an appraisal by a professional coworker of the manner in which an individual nurse conducts practice, education, or research? - correct answers.Peer review When documenting with the charting by exception method, which acronym is generally used? - correct answers.PIE (Problem, Intervention, Evaluation) A nurse on the evening shift reviews a chart and finds that the patient did not receive a morning dose of insulin as prescribed. After notifying the charge nurse, what action should the nurse take immediately? - correct answers.Complete an incident report according to hospital policy. What is the advantage of electronic health records (EHR) over electronic medical records (EMR)? - correct answers.EHR can exchange the patient data with other facilities. A nurse is documenting patient information on an electronic system. Which method would not be a safeguard to prevent unauthorized access? - correct answers.Leaving patient information on the screen for others to view At the beginning of the shift, the nurse charts a complete assessment, observations, intravenous (IV) site and rate, vital signs, and other pertinent data. During the remainder of the shift, only additional treatments withheld, new concerns, and changes in condition are charted. This reflects which form of charting? - correct answers.Charting by exception (CBE) A patient is being discharged after recovery. What does the nursing assistant do about the patient chart? - correct answers.Send the patient chart to medical records During which phase of the nursing process does provision of nursing care take place? - correct answers.Implementation While assessing a patient's report, the nurse manager notices a great deal of abnormal patient data. Which patient charting method does the nurse manager suggest? - correct answers.Charting by exception The purpose of clinical pathways is to - correct answers.Allow the development of integrated care plans for a projected length of stay. Which component of the health care record must a patient receive before discharge from a medical facility? - correct answers.A discharge summary On what basis do insurance companies decide upon reimbursement rates for a patient? - correct answers.Diagnosis-related groups (DRGs) A nurse manager wants to know if a patient is allergic to a particular medication. The health care facility uses Kardex. Why is the nurse manager not able to procure the information? - correct answers.Kardex covers the medication list without citing allergic details. Which statement is true regarding the chart (health care record)? - correct answers.It is a legal document. It may be used in the accreditation process. It may be electronic, paper, or a combination of both. It is used as a reference for reimbursement of health care costs. It facilitates accurate communication and continuity of care among members of the health care team. A health care worker accidently faxes a copy of laboratory data and test results to an incorrect fax number. The health care worker resends the fax to the correct number and makes no attempt to retrieve the data. What violation has occurred if the health care worker fails to get the fax returned? - correct answers.Health Insurance Portability and Accountability Act (HIPAA) The nurse manager has to audit whether the nursing care provided to patients adhere to the accepted standards. Which part of the documentation should the nurse manager look into? - correct answers.Nurse's notes While the nursing assistant is accessing a patient's data using an electronic health record, the nurse manager calls for an urgent meeting. What should the nursing assistant do? - correct answers.Lock the terminal. The nurse records breath sounds instead of blood sugar during documentation. Which corrective action should the nurse take in order to rectify the error? - correct answers.Draw a single line through the error and record the blood sugar What is the most likely result of a nurse improperly documenting? Multiple choice question - correct answers.An error in patient care