ATI: RN Informatics: Documenting in the Electronic Medical Record 3.0 Case Study Test Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

ATI: RN Informatics: Documenting in the Electronic Medical Record 3.0 Case Study Test Questions and Answers | Latest Version | 2025/2026 | Correct & Verified What should a nurse do immediately after administering medication in the EMR? Document the medication, dose, route, time, and client response What is the best way to ensure patient data is protected when leaving a workstation? Log out of the electronic health record What does real-time documentation in the EMR help improve? Accuracy and continuity of care What should a nurse do if they realize they charted on the wrong patient? Report the error per policy and document the correction with an addendum When documenting in an EMR, how should a nurse correct an error? 2 Use the EMR's built-in correction or amendment function, never delete or hide data Which feature in the EMR helps reduce transcription errors? Computerized provider order entry (CPOE) Why is time-stamping entries in the EMR important? It provides a legal record of when care was delivered What is the main purpose of clinical decision support tools in the EMR? To assist with evidence-based, accurate, and timely decisions What is one benefit of structured data fields in the EMR? They allow for standardized documentation and easier data retrieval What should a nurse do before entering data into a patient's record? Confirm the correct patient chart is open What does an EMR audit trail track? 3 All actions taken in a patient’s chart, including who accessed it and when When documenting a client’s refusal of care in the EMR, what is most important to include? The client’s exact words and the nurse’s response or teaching Why should nurses avoid using free-text fields excessively? They can make data harder to analyze and retrieve When entering a late entry in an EMR, what should be included? The current date and time, the label "late entry," and the original time the event occurred What does barcode medication administration (BCMA) help prevent? Medication administration errors Why is it important to use approved abbreviations in EMR documentation? To reduce the risk of misinterpretation and errors What should the nurse do if an EMR system is temporarily down? 4 Use the facility's paper downtime