NUR 376 EXAM 2 EXAM QUESTIONS WITH
COMPLETE SOLUTION
Health Information Technology for Economic and Clinical Health Act
(HITECH)
2004, President Bush set as a goal that every American would have an
electronic health record by 2014.
In 2009, as part of the Heath Information Technology for Economic and
Clinical Health (HITECH) Act, the federal government set aside $27billion
for an incentive program that encourages hospitals and providers to adopt
electronic Health Records
Problems with conversion from paper to EHR
Beforehand, several health records were either hand written or only
completed for one facility causing a lack of medical history to be assessed
by other health care members (was not very universal)
Documentation is a...
is a STANDARD identified by many accrediting, regulatory, advisory,
professional, and educational agencies or entities.
______________ of care is an imperative of providing excellence in
health care.
Documentation
An incident /occurrence report should be _______________ from
medical record/EHR
Done Seperate
Advantages of EHR (6)
1.) Standardization
2.) Accuracy
3.) Confidentiality
4.) Easy access for multiple users
5.) Providing ease in maintaining ongoing health record of client's condition
6.) Rapid acquisition and transfer of clients' Information
Challenges of EHR (3)
1.) Learning the system
2.) Knowing how to correct errors
3.) Maintaining security (protecting the privacy and safety of health
information)
,The chart or medical record is the ____________ record of care. It is
mandatory to have the _____________ of recorder.
Legal. Signature.
Documentation should be ___________, including ___________ data
and _________ data
Factual, Objective and Subjective
How should Subjective Data be documented?
In quotes, within quotation marks, or summarize and identify the
information as the client's statement.
Abbreviations and symbols used in documentation should only be
used if....
approved by The Joint Commission and the facility.
Responsibilities of Documentation(4)
1.) Documentation should be FACTUAL
2.) Documentation should be ACCURATE AND CONCISE
3.) Documentation should be COMPLETE AND CURRENT
4.) Documentation should be ORGANIZED
Never _____________ an assignment, intervention, or evaluation.
Prechart
The purpose of HIPAA Privacy Rule is....
"To assure that individual's health information is properly protected while
allowing the flow of health information needed to provide and promote high
quality health care and protect the public's health and wellbeing"
The 3 elements of documenting includes:
Information, Responsibility, and Formats
Nurses are ______________ and ______________ responsible for
ensuring confidentiality
Legally and Ethically
The only individuals that may access a client's EMR/EHR include...
only health care providers who are involved DIRECTLY in a client's care
Purpose of the Medical Record (7)
1.) COMMUNICATION: Consistent, Reflective, Cumulative
2.) LEGAL DOCUMENTATION: Record provides context, history and
actions taken in providing care, litigation
3.) FINANCIAL BILLING: Insurance payments, Medicare/Medicaid
reimbursement
4.) EDUCATION: Review of record, preparation of students to provide care
5.) RESEARCH: Concurrent, past practice, treatments, medications,
protocols
, 6.) AUDITING: Regulatory agencies, accreditation events, litigation
7.) SECURE RECORD: Access is recorded and tracked
Information that is Documented includes (6):
1.) Assessments
2.) Medication administration
3.) Nursing actions, treatment, and responses
4.) Client education
5.) Discharge planning
6.) Procedures
Formats for documentation (4)
1.) Flow charts
2.) Narrative documentation
3.) Charting by exception
4.) Problem-oriented medical recording
Flow charts
Show trends in vital signs, blood glucose levels, pain level, and other
frequent assessments
Narrative documentation
Records information as a sequence of events in a story-like manner.
Charting by exception
uses standardized forms that identify norms and allows selective
documentation of deviations from those norms
Problem-oriented medical records
Are organized by problem or diagnosis and consist of a database, problem
list, care plan, and progress notes.
SOAP, PIE, and DAR are all examples of
___________________________________
Problem-oriented medical records
SOAP
Subjective
Objective
Assessment
Plan
ADPIE
Assessment
Data
Plan
Implementation
Evaluation
DAR
COMPLETE SOLUTION
Health Information Technology for Economic and Clinical Health Act
(HITECH)
2004, President Bush set as a goal that every American would have an
electronic health record by 2014.
In 2009, as part of the Heath Information Technology for Economic and
Clinical Health (HITECH) Act, the federal government set aside $27billion
for an incentive program that encourages hospitals and providers to adopt
electronic Health Records
Problems with conversion from paper to EHR
Beforehand, several health records were either hand written or only
completed for one facility causing a lack of medical history to be assessed
by other health care members (was not very universal)
Documentation is a...
is a STANDARD identified by many accrediting, regulatory, advisory,
professional, and educational agencies or entities.
______________ of care is an imperative of providing excellence in
health care.
Documentation
An incident /occurrence report should be _______________ from
medical record/EHR
Done Seperate
Advantages of EHR (6)
1.) Standardization
2.) Accuracy
3.) Confidentiality
4.) Easy access for multiple users
5.) Providing ease in maintaining ongoing health record of client's condition
6.) Rapid acquisition and transfer of clients' Information
Challenges of EHR (3)
1.) Learning the system
2.) Knowing how to correct errors
3.) Maintaining security (protecting the privacy and safety of health
information)
,The chart or medical record is the ____________ record of care. It is
mandatory to have the _____________ of recorder.
Legal. Signature.
Documentation should be ___________, including ___________ data
and _________ data
Factual, Objective and Subjective
How should Subjective Data be documented?
In quotes, within quotation marks, or summarize and identify the
information as the client's statement.
Abbreviations and symbols used in documentation should only be
used if....
approved by The Joint Commission and the facility.
Responsibilities of Documentation(4)
1.) Documentation should be FACTUAL
2.) Documentation should be ACCURATE AND CONCISE
3.) Documentation should be COMPLETE AND CURRENT
4.) Documentation should be ORGANIZED
Never _____________ an assignment, intervention, or evaluation.
Prechart
The purpose of HIPAA Privacy Rule is....
"To assure that individual's health information is properly protected while
allowing the flow of health information needed to provide and promote high
quality health care and protect the public's health and wellbeing"
The 3 elements of documenting includes:
Information, Responsibility, and Formats
Nurses are ______________ and ______________ responsible for
ensuring confidentiality
Legally and Ethically
The only individuals that may access a client's EMR/EHR include...
only health care providers who are involved DIRECTLY in a client's care
Purpose of the Medical Record (7)
1.) COMMUNICATION: Consistent, Reflective, Cumulative
2.) LEGAL DOCUMENTATION: Record provides context, history and
actions taken in providing care, litigation
3.) FINANCIAL BILLING: Insurance payments, Medicare/Medicaid
reimbursement
4.) EDUCATION: Review of record, preparation of students to provide care
5.) RESEARCH: Concurrent, past practice, treatments, medications,
protocols
, 6.) AUDITING: Regulatory agencies, accreditation events, litigation
7.) SECURE RECORD: Access is recorded and tracked
Information that is Documented includes (6):
1.) Assessments
2.) Medication administration
3.) Nursing actions, treatment, and responses
4.) Client education
5.) Discharge planning
6.) Procedures
Formats for documentation (4)
1.) Flow charts
2.) Narrative documentation
3.) Charting by exception
4.) Problem-oriented medical recording
Flow charts
Show trends in vital signs, blood glucose levels, pain level, and other
frequent assessments
Narrative documentation
Records information as a sequence of events in a story-like manner.
Charting by exception
uses standardized forms that identify norms and allows selective
documentation of deviations from those norms
Problem-oriented medical records
Are organized by problem or diagnosis and consist of a database, problem
list, care plan, and progress notes.
SOAP, PIE, and DAR are all examples of
___________________________________
Problem-oriented medical records
SOAP
Subjective
Objective
Assessment
Plan
ADPIE
Assessment
Data
Plan
Implementation
Evaluation
DAR
