NUR 376 EXAM 2 Latest recent and
frequently tested with comprehensive
questions and verified accurate solution
(detailed & elaborated) GRADED A+
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,Health Information Technology for Economic and Clinical Health Act (HITECH) - correct ans:2004,
President Bush set as a goal that every American would have an electronic health record by 2014.
In 2009, as part of the Heath Information Technology for Economic and Clinical Health (HITECH) Act, the
federal government set aside $27billion for an incentive program that encourages hospitals and
providers to adopt electronic Health Records
Problems with conversion from paper to EHR - correct ans:Beforehand, several health records were
either hand written or only completed for one facility causing a lack of medical history to be assessed by
other health care members (was not very universal)
Documentation is a... - correct ans:is a STANDARD identified by many accrediting, regulatory, advisory,
professional, and educational agencies or entities.
______________ of care is an imperative of providing excellence in health care. - correct
ans:Documentation
An incident /occurrence report should be _______________ from medical record/EHR - correct
ans:Done Seperate
Advantages of EHR (6) - correct ans:1.) Standardization
2.) Accuracy
3.) Confidentiality
4.) Easy access for multiple users
5.) Providing ease in maintaining ongoing health record of client's condition
6.) Rapid acquisition and transfer of clients' Information
Challenges of EHR (3) - correct ans:1.) Learning the system
2.) Knowing how to correct errors
3.) Maintaining security (protecting the privacy and safety of health information)
,The chart or medical record is the ____________ record of care. It is mandatory to have the
_____________ of recorder. - correct ans:Legal. Signature.
Documentation should be ___________, including ___________ data and _________ data - correct
ans:Factual, Objective and Subjective
How should Subjective Data be documented? - correct ans:In quotes, within quotation marks, or
summarize and identify the information as the client's statement.
Abbreviations and symbols used in documentation should only be used if.... - correct ans:approved by
The Joint Commission and the facility.
Responsibilities of Documentation(4) - correct ans:1.) Documentation should be FACTUAL
2.) Documentation should be ACCURATE AND CONCISE
3.) Documentation should be COMPLETE AND CURRENT
4.) Documentation should be ORGANIZED
Never _____________ an assignment, intervention, or evaluation. - correct ans:Prechart
The purpose of HIPAA Privacy Rule is.... - correct ans:"To assure that individual's health information is
properly protected while allowing the flow of health information needed to provide and promote high
quality health care and protect the public's health and wellbeing"
The 3 elements of documenting includes: - correct ans:Information, Responsibility, and Formats
Nurses are ______________ and ______________ responsible for ensuring confidentiality - correct
ans:Legally and Ethically
The only individuals that may access a client's EMR/EHR include... - correct ans:only health care
providers who are involved DIRECTLY in a client's care
, Purpose of the Medical Record (7) - correct ans:1.) COMMUNICATION: Consistent, Reflective,
Cumulative
2.) LEGAL DOCUMENTATION: Record provides context, history and actions taken in providing care,
litigation
3.) FINANCIAL BILLING: Insurance payments, Medicare/Medicaid reimbursement
4.) EDUCATION: Review of record, preparation of students to provide care
5.) RESEARCH: Concurrent, past practice, treatments, medications, protocols
6.) AUDITING: Regulatory agencies, accreditation events, litigation
7.) SECURE RECORD: Access is recorded and tracked
Information that is Documented includes (6): - correct ans:1.) Assessments
2.) Medication administration
3.) Nursing actions, treatment, and responses
4.) Client education
5.) Discharge planning
6.) Procedures
Formats for documentation (4) - correct ans:1.) Flow charts
2.) Narrative documentation
3.) Charting by exception
4.) Problem-oriented medical recording
Flow charts - correct ans:Show trends in vital signs, blood glucose levels, pain level, and other frequent
assessments
Narrative documentation - correct ans:Records information as a sequence of events in a story-like
manner.
Charting by exception - correct ans:uses standardized forms that identify norms and allows selective
documentation of deviations from those norms
frequently tested with comprehensive
questions and verified accurate solution
(detailed & elaborated) GRADED A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
CONTACT INFORMATION
WHATAPPSLINK- https://wa.me/254784769540
,Health Information Technology for Economic and Clinical Health Act (HITECH) - correct ans:2004,
President Bush set as a goal that every American would have an electronic health record by 2014.
In 2009, as part of the Heath Information Technology for Economic and Clinical Health (HITECH) Act, the
federal government set aside $27billion for an incentive program that encourages hospitals and
providers to adopt electronic Health Records
Problems with conversion from paper to EHR - correct ans:Beforehand, several health records were
either hand written or only completed for one facility causing a lack of medical history to be assessed by
other health care members (was not very universal)
Documentation is a... - correct ans:is a STANDARD identified by many accrediting, regulatory, advisory,
professional, and educational agencies or entities.
______________ of care is an imperative of providing excellence in health care. - correct
ans:Documentation
An incident /occurrence report should be _______________ from medical record/EHR - correct
ans:Done Seperate
Advantages of EHR (6) - correct ans:1.) Standardization
2.) Accuracy
3.) Confidentiality
4.) Easy access for multiple users
5.) Providing ease in maintaining ongoing health record of client's condition
6.) Rapid acquisition and transfer of clients' Information
Challenges of EHR (3) - correct ans:1.) Learning the system
2.) Knowing how to correct errors
3.) Maintaining security (protecting the privacy and safety of health information)
,The chart or medical record is the ____________ record of care. It is mandatory to have the
_____________ of recorder. - correct ans:Legal. Signature.
Documentation should be ___________, including ___________ data and _________ data - correct
ans:Factual, Objective and Subjective
How should Subjective Data be documented? - correct ans:In quotes, within quotation marks, or
summarize and identify the information as the client's statement.
Abbreviations and symbols used in documentation should only be used if.... - correct ans:approved by
The Joint Commission and the facility.
Responsibilities of Documentation(4) - correct ans:1.) Documentation should be FACTUAL
2.) Documentation should be ACCURATE AND CONCISE
3.) Documentation should be COMPLETE AND CURRENT
4.) Documentation should be ORGANIZED
Never _____________ an assignment, intervention, or evaluation. - correct ans:Prechart
The purpose of HIPAA Privacy Rule is.... - correct ans:"To assure that individual's health information is
properly protected while allowing the flow of health information needed to provide and promote high
quality health care and protect the public's health and wellbeing"
The 3 elements of documenting includes: - correct ans:Information, Responsibility, and Formats
Nurses are ______________ and ______________ responsible for ensuring confidentiality - correct
ans:Legally and Ethically
The only individuals that may access a client's EMR/EHR include... - correct ans:only health care
providers who are involved DIRECTLY in a client's care
, Purpose of the Medical Record (7) - correct ans:1.) COMMUNICATION: Consistent, Reflective,
Cumulative
2.) LEGAL DOCUMENTATION: Record provides context, history and actions taken in providing care,
litigation
3.) FINANCIAL BILLING: Insurance payments, Medicare/Medicaid reimbursement
4.) EDUCATION: Review of record, preparation of students to provide care
5.) RESEARCH: Concurrent, past practice, treatments, medications, protocols
6.) AUDITING: Regulatory agencies, accreditation events, litigation
7.) SECURE RECORD: Access is recorded and tracked
Information that is Documented includes (6): - correct ans:1.) Assessments
2.) Medication administration
3.) Nursing actions, treatment, and responses
4.) Client education
5.) Discharge planning
6.) Procedures
Formats for documentation (4) - correct ans:1.) Flow charts
2.) Narrative documentation
3.) Charting by exception
4.) Problem-oriented medical recording
Flow charts - correct ans:Show trends in vital signs, blood glucose levels, pain level, and other frequent
assessments
Narrative documentation - correct ans:Records information as a sequence of events in a story-like
manner.
Charting by exception - correct ans:uses standardized forms that identify norms and allows selective
documentation of deviations from those norms
