ATI Fundamentals Documentation QUESTIONS AND ANSWERS 100% ACCURATE.
CPOE systems allow provider prescriptions to be transmitted more quickly from one department
to another, which can increase the speed of care delivery for clients.
A nurse is preparing an in-service about HIPAA. Which of the following information should the
nurse plan to include?
A. "Accessing the medical record of clients on units other than where you are assigned is
allowed."
B. "There are large financial penalties for charting vital signs you obtain for another nurse's
client."
C. "Personnel can be terminated for breaching a client's confidentiality."
D. "Once you have cared for a client, it is acceptable to look at their medical record on
subsequent health care visits." C. "Personnel can be terminated for breaching a client's
confidentiality."
The nurse should plan to inform the group that strong penalties exist for HIPAA violations,
which include breaching client confidentiality. Penalties include termination from the facility,
imprisonment, loss of professional licensure, or fines.
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following
entries should the nurse identify as meeting the American Nurses Association (ANA) standards
for documentation?
A. "The client is now asleep, and they ate most of their breakfast a few hours ago."
B. "The client vomited 240 mL of clear emesis but denies pain or nausea."
C. "The client reports not feeling good, but they look fine."
D. "The client has 8 to 10 sores on their body." B. "The client vomited 240 mL of clear
emesis but denies pain or nausea."
According to ANA standards, documentation should be factual and complete. Information
charted here includes measurements, visual observations, and client data.
A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's
office. Which of the following characteristics should the charge nurse plan to include? (Select all
that apply.)
A. Reduces medical errors
B. Improves listening skills among interdisciplinary team members
C. Less convenient than paper-based charting
D. Makes client medical history more easily available
E. Increases accuracy of coding procedures A. Reduces medical errors is correct. The charge
nurse should inform the staff that electronic documentation systems can help reduce medical
errors.
D. Makes client medical history more easily available is correct. The charge nurse should include
that electronic records help to make client information readily available to health care
professionals.
CPOE systems allow provider prescriptions to be transmitted more quickly from one department
to another, which can increase the speed of care delivery for clients.
A nurse is preparing an in-service about HIPAA. Which of the following information should the
nurse plan to include?
A. "Accessing the medical record of clients on units other than where you are assigned is
allowed."
B. "There are large financial penalties for charting vital signs you obtain for another nurse's
client."
C. "Personnel can be terminated for breaching a client's confidentiality."
D. "Once you have cared for a client, it is acceptable to look at their medical record on
subsequent health care visits." C. "Personnel can be terminated for breaching a client's
confidentiality."
The nurse should plan to inform the group that strong penalties exist for HIPAA violations,
which include breaching client confidentiality. Penalties include termination from the facility,
imprisonment, loss of professional licensure, or fines.
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following
entries should the nurse identify as meeting the American Nurses Association (ANA) standards
for documentation?
A. "The client is now asleep, and they ate most of their breakfast a few hours ago."
B. "The client vomited 240 mL of clear emesis but denies pain or nausea."
C. "The client reports not feeling good, but they look fine."
D. "The client has 8 to 10 sores on their body." B. "The client vomited 240 mL of clear
emesis but denies pain or nausea."
According to ANA standards, documentation should be factual and complete. Information
charted here includes measurements, visual observations, and client data.
A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's
office. Which of the following characteristics should the charge nurse plan to include? (Select all
that apply.)
A. Reduces medical errors
B. Improves listening skills among interdisciplinary team members
C. Less convenient than paper-based charting
D. Makes client medical history more easily available
E. Increases accuracy of coding procedures A. Reduces medical errors is correct. The charge
nurse should inform the staff that electronic documentation systems can help reduce medical
errors.
D. Makes client medical history more easily available is correct. The charge nurse should include
that electronic records help to make client information readily available to health care
professionals.
