NUR 110 EXAM 4 Questions with
Solutions
Nursing action that produces a written account of pertinent patient data, nursing clinical decisions and
interventions, and patient responses in a health record. - Answer-Documentation
Purposes of medical record: - Answer-facilitates interdisciplinary communication.
provides a legal record of care provided.
justify financial billing/reimbursement.
allows for auditing, monitoring, and evaluation of care provided.
Also serve as research data and learning sources.
Common mistakes in documentation that result in malpractice: - Answer-failing to record pertinent
health or drug information.
failing to record nursing action.
failing to record medication administration.
failing to record drug reactions or changes in patients condition.
incomplete or illegible records.
failing to document discontinued medications.
, Insurance companies use the documentation of severity of illness, intensity of services received, and
quality of care provided to determine ________ for health care services. - Answer-Reimbursement
Accrediting agencies such as ___ require quality improvement programs and set standards for the
information needed in patient records, including evidence of an individualized plan of care developed
with patient's input, discharge planning, and patient education. - Answer-TJC (the joint commission)
In order to use patient's information for research you must... - Answer-Go to the institutional review
board (IRB) and get their approval.
Patient record's include: - Answer-diagnosis, signs and symptoms, successful/unsuccessful therapies,
diagnostic findings, patient behaviors.
Need to document in a: - Answer-accurate, timely, concise, and effective manner to develop and
maintain an effective, organized, and comprehensive plan of care.
______ was the first federal legislation providing protection for patient records. - Answer-HIPPAA
The ___________ requires that requests regarding health information be limited to the specific
information requested. - Answer-Privacy rule
__________ specifies administrative, physical, and technical safeguards, for 18 defined elements of
protected health information in electronic form. - Answer-Security rule
PHI includes individually identifiable health information such as: - Answer-demographic data
facts that relate to an individual's past, present, future, or physical/mental health conditions
provision of care
payment for the provision of care that identifies the individual
Solutions
Nursing action that produces a written account of pertinent patient data, nursing clinical decisions and
interventions, and patient responses in a health record. - Answer-Documentation
Purposes of medical record: - Answer-facilitates interdisciplinary communication.
provides a legal record of care provided.
justify financial billing/reimbursement.
allows for auditing, monitoring, and evaluation of care provided.
Also serve as research data and learning sources.
Common mistakes in documentation that result in malpractice: - Answer-failing to record pertinent
health or drug information.
failing to record nursing action.
failing to record medication administration.
failing to record drug reactions or changes in patients condition.
incomplete or illegible records.
failing to document discontinued medications.
, Insurance companies use the documentation of severity of illness, intensity of services received, and
quality of care provided to determine ________ for health care services. - Answer-Reimbursement
Accrediting agencies such as ___ require quality improvement programs and set standards for the
information needed in patient records, including evidence of an individualized plan of care developed
with patient's input, discharge planning, and patient education. - Answer-TJC (the joint commission)
In order to use patient's information for research you must... - Answer-Go to the institutional review
board (IRB) and get their approval.
Patient record's include: - Answer-diagnosis, signs and symptoms, successful/unsuccessful therapies,
diagnostic findings, patient behaviors.
Need to document in a: - Answer-accurate, timely, concise, and effective manner to develop and
maintain an effective, organized, and comprehensive plan of care.
______ was the first federal legislation providing protection for patient records. - Answer-HIPPAA
The ___________ requires that requests regarding health information be limited to the specific
information requested. - Answer-Privacy rule
__________ specifies administrative, physical, and technical safeguards, for 18 defined elements of
protected health information in electronic form. - Answer-Security rule
PHI includes individually identifiable health information such as: - Answer-demographic data
facts that relate to an individual's past, present, future, or physical/mental health conditions
provision of care
payment for the provision of care that identifies the individual
