EAQ: Documentation and Informatics
CPOE reduces transcription errors - A group of nurses are discussing the advantages of using
computerized provider order entry (CPOE). Which statements indicate that the nurses understand the
major advantage of using CPOE?
the patient had two cups of soup and it was tolerated well - The primary healthcare provider
orders a clear liquids diet for a patient with gastritis. On the first day, the patient consumes soup and
tolerates it well. How does the nurse document this finding?
enter only objective and subjective information - A manager who is reviewing the nurses' notes in
a patient's medical record finds the following entry, "The patient is difficult to care for and refuses
suggestions for improving appetite." Which directions does the manager give to the staff nurse who
entered the note?
oral communication and written reports - Communication among the members of a healthcare
team is essential to providing quality care to patients. Which are the modes for exchanging information
among the members of the healthcare team?
hand off report - At the end of a shift, the nurse documents a patient's condition, anticipated
condition, medications, and nursing interventions fulfilled so that the next nurse can follow the
appropriate treatment plan and care for the patient. What is this kind of report?
the patients incision site looks clean without any purulent drainage or erythema - The nurse
assesses a patient on day 3 after surgery and charts a progress note in the SOAP (subjective data,
objective data, assessment, and plan) format. Which is considered an objective datum?
you need to use words that the patients understand when writing a teaching sheet - You are
helping to design a new teaching sheet that will go home with patients who are discharged home from
your unit. Which option do you need to remember when designing the teaching sheet?
HIPPA - The nurse faxes a patient's medical record to an unknown number. Which law is the nurse
violating?
, transfer reports - A patient was shifted from the intensive care unit to the cardiac unit. What kinds
of reports are used to communicate between the two units?
dietary restrictions, emergency contact numbers, follow-up care - The nurse is preparing a patient
for discharge. What should the nurse include in the discharge summary forms?
the new nurse gives a newly ordered medication before entering the order in the patients medical
record - A new graduate nurse is providing a telephone report to a patient's healthcare provider
and accepting telephone orders from the provider. Which actions require the new nurse's preceptor to
intervene?
it helps in determining the diagnosis-related group of the patient - How is proper documentation
of a patient's health information useful to medical insurance companies? Choose the best answer.
admission sheet - The nurse is recording specific demographic information about a patient in a
hospital. Which section of the traditional source record does the nurse use to record this information?
charting by exception - The nurse is given a form with preset standard findings for recording a
progress note. The nurse reports the findings in the following way: "Physical Exam: All systems within
normal except left lower extremity, casted d/t to heel fracture. Review of Systems: All normal except pain
in the left foot." What kind of documentation and informatics is this?
assessment - The nurse interprets the subjective and objective data and diagnoses a problem in a
patient. Which step of the nursing process reflects this interpretation, according to SOAPIE (subjective,
objective, assessment, plan, intervention, and evaluation) format?
"I should leave spaces with unknown information blank" - A registered nurse is teaching a group
of student nurses about legal guidelines for the effective recording of a patient's data on a handwritten
paper document. Which statement by a student nurse needs correction?
CPOE reduces transcription errors - A group of nurses are discussing the advantages of using
computerized provider order entry (CPOE). Which statements indicate that the nurses understand the
major advantage of using CPOE?
the patient had two cups of soup and it was tolerated well - The primary healthcare provider
orders a clear liquids diet for a patient with gastritis. On the first day, the patient consumes soup and
tolerates it well. How does the nurse document this finding?
enter only objective and subjective information - A manager who is reviewing the nurses' notes in
a patient's medical record finds the following entry, "The patient is difficult to care for and refuses
suggestions for improving appetite." Which directions does the manager give to the staff nurse who
entered the note?
oral communication and written reports - Communication among the members of a healthcare
team is essential to providing quality care to patients. Which are the modes for exchanging information
among the members of the healthcare team?
hand off report - At the end of a shift, the nurse documents a patient's condition, anticipated
condition, medications, and nursing interventions fulfilled so that the next nurse can follow the
appropriate treatment plan and care for the patient. What is this kind of report?
the patients incision site looks clean without any purulent drainage or erythema - The nurse
assesses a patient on day 3 after surgery and charts a progress note in the SOAP (subjective data,
objective data, assessment, and plan) format. Which is considered an objective datum?
you need to use words that the patients understand when writing a teaching sheet - You are
helping to design a new teaching sheet that will go home with patients who are discharged home from
your unit. Which option do you need to remember when designing the teaching sheet?
HIPPA - The nurse faxes a patient's medical record to an unknown number. Which law is the nurse
violating?
, transfer reports - A patient was shifted from the intensive care unit to the cardiac unit. What kinds
of reports are used to communicate between the two units?
dietary restrictions, emergency contact numbers, follow-up care - The nurse is preparing a patient
for discharge. What should the nurse include in the discharge summary forms?
the new nurse gives a newly ordered medication before entering the order in the patients medical
record - A new graduate nurse is providing a telephone report to a patient's healthcare provider
and accepting telephone orders from the provider. Which actions require the new nurse's preceptor to
intervene?
it helps in determining the diagnosis-related group of the patient - How is proper documentation
of a patient's health information useful to medical insurance companies? Choose the best answer.
admission sheet - The nurse is recording specific demographic information about a patient in a
hospital. Which section of the traditional source record does the nurse use to record this information?
charting by exception - The nurse is given a form with preset standard findings for recording a
progress note. The nurse reports the findings in the following way: "Physical Exam: All systems within
normal except left lower extremity, casted d/t to heel fracture. Review of Systems: All normal except pain
in the left foot." What kind of documentation and informatics is this?
assessment - The nurse interprets the subjective and objective data and diagnoses a problem in a
patient. Which step of the nursing process reflects this interpretation, according to SOAPIE (subjective,
objective, assessment, plan, intervention, and evaluation) format?
"I should leave spaces with unknown information blank" - A registered nurse is teaching a group
of student nurses about legal guidelines for the effective recording of a patient's data on a handwritten
paper document. Which statement by a student nurse needs correction?
