YOOST & CRAWFORD FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLABORATIVE PRACTICE, 2ND EDITION

YOOST & CRAWFORD FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLABORATIVE PRACTICE, 2ND EDITION.Chapter 10: Documentation, Electronic Health Records, and Reporting MULTIPLE CHOICE 1. The nurse understands the need for accurate documentation due to which fact? a. Accurate documentation is needed for proper reimbursement. b. Accurate documentation must be electronically generated. c. Accurate documentation does not include e-mails or faxes. d. Accurate documentation is only accepted in court if written by hand. ANS: A Accurate documentation is necessary for hospitals to be reimbursed according to diagnostic- related groups (DRGs). DRGs are a system used to classify hospital admissions. Health care documentation is any written or electronically generated information about a patient that describes the patient, the patient’s health, and the care and services provided, including the dates of care. These records may be paper or electronic documents, such as electronic medical records, faxes, e-mails, audiotapes, videotapes, and images. All such records are considered legal documentation and may be used in court. DIF: Remembering OBJ: 10.1 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Communication 2. The nurse identifies which statement to be true regarding nursing documentation? a. Standards for documentation are established by a national commission. b. Medical records should be accessible to everyone. c. Documentation should not include the patient’s diagnosis. d. High-quality nursing documentation reflects the nursing process. ANS: D The ANA’s model for high-quality nursing documentation reflects the nursing process and includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and retrievability. Standards for documentation are established by each health care organization’s policies and procedures. They should be in agreement with The Joint Commission’s standards and elements of performance, including having a medical record for each patient that is accessed only by authorized personnel. General principles of medical record documentation from the Centers for Medicare and Medicaid Services (2017) include the need for completeness and legibility; the reasons for each patient encounter, including assessments and diagnosis; and the plan of care, the patient’s progress, and any changes in diagnosis and treatment.