NR224 Documentation and Informatics
_in the patient's health record provides an account of their Information
health in the past, is the place where new information about documented
their health is _, and can provide cues to what their health
may be like in the future. Health professionals contribute to
the patient's health record by .. assessments, identifying
problems, prescribing treatment, and evaluating the
individual's response to treatment. Accurate .. ensures
continuity of care, saves time, and minimizes the risk of
errors.
What are the benefits of using an electronic health record 1
(EHR) for the health professional? 2
3
1 Continuity of care 5
2 Ability to document clinical reasoning 6
3 All data is readily accessible
4 Data not secure
5 Remote access
6 Access to records anytime
7 Does not allow manual data entry
Page 1 of 15
, NR224 Documentation and Informatics
EMR/EHR 1 EHR
2 EMR
1 A longitudinal record of an individual's interactions with the
healthcare system.
2 The legal record documenting a single encounter between
an individual and a healthcare professional.
REFER TO IMAGE 2 3
The nurse working the evening shift is recording a blood
pressure taken at the time shown on the clock. How is the
time written using the 24-hour clock?
1. 0800
2. 8:00 a.m.
3. 2000
4. 8:00 p.m.
The medical record provides: 1 ASYNCHRONOUS
2 LEGAL
1 a means of _ communication for health professionals 3 REIMBURSMENT
collaborating on the care of an individual; 4 AUDITING
2 _ documentation of care encounters; 5 HEALTH RECORD
3 a source to validate the costs of care for _;
4 a source of information for _ and monitoring the standards
of care provided;
5 data for research; and education.
Additionally, most electronic health records (EHRs) provide
patients with access to their complete _
Page 2 of 15
_in the patient's health record provides an account of their Information
health in the past, is the place where new information about documented
their health is _, and can provide cues to what their health
may be like in the future. Health professionals contribute to
the patient's health record by .. assessments, identifying
problems, prescribing treatment, and evaluating the
individual's response to treatment. Accurate .. ensures
continuity of care, saves time, and minimizes the risk of
errors.
What are the benefits of using an electronic health record 1
(EHR) for the health professional? 2
3
1 Continuity of care 5
2 Ability to document clinical reasoning 6
3 All data is readily accessible
4 Data not secure
5 Remote access
6 Access to records anytime
7 Does not allow manual data entry
Page 1 of 15
, NR224 Documentation and Informatics
EMR/EHR 1 EHR
2 EMR
1 A longitudinal record of an individual's interactions with the
healthcare system.
2 The legal record documenting a single encounter between
an individual and a healthcare professional.
REFER TO IMAGE 2 3
The nurse working the evening shift is recording a blood
pressure taken at the time shown on the clock. How is the
time written using the 24-hour clock?
1. 0800
2. 8:00 a.m.
3. 2000
4. 8:00 p.m.
The medical record provides: 1 ASYNCHRONOUS
2 LEGAL
1 a means of _ communication for health professionals 3 REIMBURSMENT
collaborating on the care of an individual; 4 AUDITING
2 _ documentation of care encounters; 5 HEALTH RECORD
3 a source to validate the costs of care for _;
4 a source of information for _ and monitoring the standards
of care provided;
5 data for research; and education.
Additionally, most electronic health records (EHRs) provide
patients with access to their complete _
Page 2 of 15
