Chapter 10: Informatics and Documentation

Chapter 10: Informatics and Documentation

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. A nurse works at a health care organization that is accredited by The Joint Commission. What is the best method for this health care organization to demonstrate that it is providing quality patient care?

a.	Cost of care per patient day
b.	Number of registered nurses
c.	Absence of sentinel events
d.	Documentation audits

 

 

ANS:   D

Regulations from agencies such as The Joint Commission and the Centers for Medicare and Medicaid Services require health care institutions to monitor and evaluate the quality and appropriateness of patient care. Typically, such monitoring and evaluations occur through the auditing of information health care providers document in patient records. It does not include cost of care per patient day, number of RNs, nor absence of sentinel events.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    163                  OBJ:    Identify key reasons for reporting and recording patient care.

TOP:    Nursing Process: Evaluation              MSC:   NCLEX: Management of Care

 

2. A registered nurse is caring for an older adult patient with lung cancer. The daughter, who is also a nurse, asks to see the chart. What is the nurse’s best response?

a.	“Come with me and we will look at it together.”
b.	“I’m sorry; this information is confidential.”
c.	“Let me ask my supervisor if it is okay.”
d.	“You should know better than to ask me that.”

 

 

ANS:   B

Do not disclose information about patients’ status to other patients, family members (unless granted by the patient), or health care staff not involved in their care. Looking at it together is not acceptable because confidentiality would be broken. Asking a supervisor is inappropriate because the nurse should already know the legalities for confidentiality. Saying, “You should know better than to ask me that” is inappropriate and condescending.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    163

OBJ:    Describe guidelines for effective documentation and reporting in a variety of health care settings. TOP:            Nursing Process: Implementation

MSC:   NCLEX: Management of Care

 

3. A nursing student is working on a clinical assignment. Which information is acceptable for the student to write on the clinical care plan that will be given to the instructor?

a.	Patient room number
b.	Patient date of birth
c.	Patient medical record number
d.	Patient nursing diagnosis

 

 

ANS:   D

The nursing diagnosis is acceptable information to give to a nursing instructor. To further maintain confidentiality and protect patient privacy, make sure written materials used in student clinical practice do not have patient identifiers, such as room number, date of birth, medical record number, or other identifiable demographic information.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    163

OBJ:    Describe guidelines for effective documentation and reporting in a variety of health care settings. TOP:            Nursing Process: Planning

MSC:   NCLEX: Management of Care

 

4. A nurse is working in an agency with standards that require a nurse’s documentation to be within the context of the nursing process. The nurse is working for which agency?

a.	Centers for Disease Control and Prevention accredited hospital
b.	World Health Organization hospital
c.	The Joint Commission accredited hospital
d.	Agency for Healthcare Research and Quality hospital

 

 

ANS:   C

The Joint Commission standard for record of care, treatment, and services requires that your documentation be within the context of the nursing process, including evidence of patient and family teaching and discharge planning. Other standards include those directed by state and federal regulatory agencies such as HIPAA, as enforced through the Department of Justice, and the Centers for Medicare and Medicaid Services.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    164

OBJ:    Describe guidelines for effective documentation and reporting in a variety of health care settings. TOP:            Nursing Process: Evaluation

MSC:   NCLEX: Management of Care