perioperative health care information
management UPDATED ACTUAL Exam
Questions and CORRECT Answers
What information does the documentation in the patient's health care record include? -
CORRECT ANSWER - current and past health status, nursing diagnoses and
interventions, expected patient outcomes, and evaluation of the patient's response.
Repeated patient care and electronic documentation can become a nursing cognitive disruption.
What are some things you can do to work efficiently and timely in this multi-task process? -
CORRECT ANSWER - By simplifying processes, standardizing and organizing data
capture.
What is PNDS? - CORRECT ANSWER - A controlled, structured, and coded nursing
language that describes perioperative nursing's influence in the effectiveness and safety of patient
care deliver, and the contributions of perioperative nursing toward patient outcomes.
What are the phases of the perioperative patient care continuum? - CORRECT ANSWER -
preadmission, preoperative, intraoperative, postoperative
As a perioperative nurse, what should you be familiar with about the structured vocabularies in
your clinical documentation? - CORRECT ANSWER - The value that structured
terminology brings to clinical documentation, the conceptual framework of the PNDS, the
contributions of the PNDS to perioperative nursing practice and patient outcomes and how
standardized documentation facilities benchmarks, comparative analysis, and efficiency
reporting.
What are included in the patient care orders in the perioperative documentation? - CORRECT
ANSWER - orders for interventions (must be entered as close to the time when the order is
communicated), verbal orders, standing orders, orders on surgeon preference cards, and order
sets. All must be dated, timed, and authenticated by the ordering health care practitioner.
, The standards of nursing practice require that documentation is base on which of the following? -
CORRECT ANSWER - Patients's condition or need and the relationship of the condition
or need to the proposed intervention.
What does a properly executed informed consent include? - CORRECT ANSWER - Name
of the health care facility providing the surgery, specific name of the intervention, indications of
the proposed intervention, name of the responsible health care provider performing the
intervention, statement identifying the risks and benefits associated with the proposed
intervention and indication that a discussion took place with the patient or patient representative,
signature of the patient or patient's representative, date and time the patient or patients
representative signed the informed consent document, date and time and signature of the witness
signing the informed consent document, signature of the responsible health care provider who
discussed the informed consent document with the content or the patient's legal representative.
Important guidelines to remember that you make nursing diagnoses and not medical diagnosis or
conclusions - CORRECT ANSWER - you are a nurse who has sound nursing judgment
but not a physician, your description should be free from bias, when patient makes a statement
make a statement do not make it appear as a statement of fact (instead write, "Patient stated
that...), use the patients statement to verify your findings but write it accordingly, document
significant changes in a timely manner, document any patient education as well as all discharge
instructions, be a patient advocate, document any communication with the patient
important guidelines about not postdating info - CORRECT ANSWER - Don't add info
after the fact, forensics lab are able to test the ink and tell if something was altered,
True or false? - CORRECT ANSWER - The Privacy Rule, a Federal law, gives an
individual rights over their health information and sets rules and limits on who can look at and
receive individual's health information.
components of perioperative documentation includes - CORRECT ANSWER - Patient
indentification, patient assessment, patient history, verification of surgical procedure, informed
consent, perioperative orders, development of a plan of care
Patient assessment info should be recorded in the chart. this information should include -
CORRECT ANSWER - risk of hypothermia, DVT, difficult airway, surgical site infection,
order of antibiotic prophylaxis, perioperative visits by the surgeon and anesthesia care provider,
management UPDATED ACTUAL Exam
Questions and CORRECT Answers
What information does the documentation in the patient's health care record include? -
CORRECT ANSWER - current and past health status, nursing diagnoses and
interventions, expected patient outcomes, and evaluation of the patient's response.
Repeated patient care and electronic documentation can become a nursing cognitive disruption.
What are some things you can do to work efficiently and timely in this multi-task process? -
CORRECT ANSWER - By simplifying processes, standardizing and organizing data
capture.
What is PNDS? - CORRECT ANSWER - A controlled, structured, and coded nursing
language that describes perioperative nursing's influence in the effectiveness and safety of patient
care deliver, and the contributions of perioperative nursing toward patient outcomes.
What are the phases of the perioperative patient care continuum? - CORRECT ANSWER -
preadmission, preoperative, intraoperative, postoperative
As a perioperative nurse, what should you be familiar with about the structured vocabularies in
your clinical documentation? - CORRECT ANSWER - The value that structured
terminology brings to clinical documentation, the conceptual framework of the PNDS, the
contributions of the PNDS to perioperative nursing practice and patient outcomes and how
standardized documentation facilities benchmarks, comparative analysis, and efficiency
reporting.
What are included in the patient care orders in the perioperative documentation? - CORRECT
ANSWER - orders for interventions (must be entered as close to the time when the order is
communicated), verbal orders, standing orders, orders on surgeon preference cards, and order
sets. All must be dated, timed, and authenticated by the ordering health care practitioner.
, The standards of nursing practice require that documentation is base on which of the following? -
CORRECT ANSWER - Patients's condition or need and the relationship of the condition
or need to the proposed intervention.
What does a properly executed informed consent include? - CORRECT ANSWER - Name
of the health care facility providing the surgery, specific name of the intervention, indications of
the proposed intervention, name of the responsible health care provider performing the
intervention, statement identifying the risks and benefits associated with the proposed
intervention and indication that a discussion took place with the patient or patient representative,
signature of the patient or patient's representative, date and time the patient or patients
representative signed the informed consent document, date and time and signature of the witness
signing the informed consent document, signature of the responsible health care provider who
discussed the informed consent document with the content or the patient's legal representative.
Important guidelines to remember that you make nursing diagnoses and not medical diagnosis or
conclusions - CORRECT ANSWER - you are a nurse who has sound nursing judgment
but not a physician, your description should be free from bias, when patient makes a statement
make a statement do not make it appear as a statement of fact (instead write, "Patient stated
that...), use the patients statement to verify your findings but write it accordingly, document
significant changes in a timely manner, document any patient education as well as all discharge
instructions, be a patient advocate, document any communication with the patient
important guidelines about not postdating info - CORRECT ANSWER - Don't add info
after the fact, forensics lab are able to test the ink and tell if something was altered,
True or false? - CORRECT ANSWER - The Privacy Rule, a Federal law, gives an
individual rights over their health information and sets rules and limits on who can look at and
receive individual's health information.
components of perioperative documentation includes - CORRECT ANSWER - Patient
indentification, patient assessment, patient history, verification of surgical procedure, informed
consent, perioperative orders, development of a plan of care
Patient assessment info should be recorded in the chart. this information should include -
CORRECT ANSWER - risk of hypothermia, DVT, difficult airway, surgical site infection,
order of antibiotic prophylaxis, perioperative visits by the surgeon and anesthesia care provider,
