Chapter 10: Documentation, Electronic Health Records, and Reporting – Flashcards

Answer: b Use of EHRs can improve access to patients' information. An unlimited number of people at a time can access a patient's medical record. Nursing documentation is an essential part of nursing care, whether it is completed on paper or electronically. The potential for medication errors decreases when electronic medication administration records are used.

Answer: c This entry is concise, complete, and objective. It gives exact times, pain levels, and nursing interventions performed. Using terms like good or grumpy are subjective judgments or opinions and should be avoided. Stating a patient complaint would be okay if it listed specific times of occurrence, nursing assessment performed, and the nursing interventions performed to correct the issue.

Answer: c As part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and updated in 2009 in The American Recovery and Reinvestment Act (ARRA), patients' rights include obtaining, viewing, or updating a copy of their own medical records. Usually an EHR copy is sent to the patient within 30 days. Facilities can charge the patient for the cost incurred in copying and sending medical records. Methods for implementation vary by facility and type of medical record. The Code for Nurses does not control who has access to medical records. Requests would go through the medical records department, or whoever is responsible for obtaining and copying patient records.

Answers: a, b, c, e Documentation in the medical record is important for reimbursement for care, for providing a record of services, for communication between providers, and for promoting continuity of care. The record is a legal document, not a non-legal document.

Answer: b Without special permission from the patient, only those with a need-to-know-the-information-for-care reasons have access to the medical record. The patient has a legal right to control access to personal information, and the nurse should not give the sister the chart for review, even with the patient present. It is best to be honest and explain the patient's legal rights rather than avoiding the subject.

Answer: a The S in SBAR stands for situation. In this case, the patient is resting, and the pain is rated 3 of 10 one hour after receiving a narcotic analgesic. Describing the admission reason and time provides the background (B). Assessment (A) of this patient revealed pain rated 8 of 10 before giving pain medication. The nurse's recommendation (R) is that pain should be assessed every 2 hours and that pain medications should be given as prescribed.

Answer: c No special computer or information technology knowledge is needed to record on a paper medical record. Paper charts are available to only one health care team member at a time. Paper records require a lot of storage space, or have to be scanned into an electronic record to reduce storage space. There is no guarantee that a pen will be available on a nursing unit or in a patient room.

ANS: D The confidentiality of patient information must be safeguarded and the information shared only with individuals who have a need and a right to know. Nurses have a professional and legal obligation to protect patient information.

Answers: b, c, d, e Documentation should be completed in a timely manner, be relevant and concise, and be accurate and factual. Inconsequentiality suggests a lack of importance, and documentation is an important part of patient care and nursing responsibility.

Answer: b All medications and nursing care should be documented as it is completed to ensure that documentation occurs in a timely manner. Documentation should occur as soon as possible after assessment, interventions (including medication administration), condition changes, or evaluation. Documentation only at the end of a shift or after meals would not be timely and could lead to medication errors and fragmented care. Nursing documentation is a legal record and is done electronically or in ink so that it cannot be changed. Errors are corrected in a specific way depending on the type of charting, but the original documentation would still be accessible.

ANS: A When an unusual and unexpected event involving a patient, visitor, or staff member occurs, an incident report is completed. An incident may be the occurrence of a fall, a medication error, or an equipment malfunction. The purpose of this report is to document the details of the incident immediately to ensure accuracy.

ANS: D The electronic health record (EHR) includes documentation over time from inpatient and outpatient sources. Laboratory data and other test results are available in inpatient and outpatient settings so that care decisions can be made. Adoption of an EHR system produces major cost savings through gains in productivity and error reduction, which ultimately improves patient health status.

ANS: A CPOE allows clinicians to enter orders in a computer that are sent directly to the appropriate department.

Answer: a A handoff report shares patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety. The handoff report is usually shared among direct caregivers. Doctors are kept informed verbally by the nurse, through SBAR reporting, and by accessing the EHR. A patient being discharged to home is given discharge instructions but is not being "handed off" to another caregiver, so a handoff report is not appropriate. Patient assignments are determined before a handoff report is needed and are based on patient acuity, staffing, and a number of other factors.

ANS: A General principles of medical record documentation from the Centers for Medicare and Medicaid Services (2010) include the need for completeness and legibility; the reasons for each patient encounter, including assessments and diagnosis; and the plan of care, the patient's progress, and any changes in diagnosis and treatment. They do not require nursing opinions.

ANS: C Charting by exception (CBE) is documentation that records only abnormal or significant data. It reduces charting time by assuming certain norms. For this type of charting, each facility must define what is normal. Any assessment finding outside normal is charted as an exception.

ANS: A Access to an EHR is controlled through assignment of individual passwords and verification codes that identify people who have the right to enter the record. Passwords should never be shared with anyone. Health care information systems have the ability to track who uses the system and which records are accessed. These organizational tools contribute to the protection of personal health information.

ANS: C The ANA's model for high-quality nursing documentation reflects the nursing process.

ANS: A, B, C The medical record is the legal documentation of care provided to a patient. In the event of litigation, the medical record is often the only available evidence of the event in question. Medical record documentation should be based on fact, not opinions. Every note in a medical record must include a date, time, and signature with credentials. Ethical practice dictates that nurses document only interventions that are performed. Medical record entries cannot be altered or obliterated.

ANS: A, B, C The medical record is a document with comprehensive information about a patient's health care encounter, as well as demographic, administrative, and clinical data. The record serves as the major communication tool between staff members and as a single data access point for everyone involved in the patient's care. It is a legal document that must meet guidelines for completeness, accuracy, timeliness, accessibility, and authenticity.