Chapter 09: Informatics and Documentation

Chapter 09: Informatics and Documentation

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. Regulations from agencies such as The Joint Commission and the Centers for Medicare and Medicaid Services require the monitoring and evaluation of the quality and appropriateness of patient care. What is the best method for demonstrating that an organization is providing quality patient care?

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.

PTS:    1                      DIF:    Cognitive Level: Application             REF:    146

OBJ:    Discuss the relationship between informatics and quality health care

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Safe and Effective Care Environment

2. Sadie, a registered nurse was caring for Mr. Harris, an older adult patient with lung cancer. His daughter, a nurse, asked Sadie to let her look at Mr. Harris’ chart. Sadie’s best reply should be:

ANS:   B

Do not disclose information about patients’ status to other patients, family members (unless granted by the patient), or to health care staff not involved in their care. Legal and ethical obligations require nurses to keep information about patients strictly confidential.

PTS:    1                      DIF:    Cognitive Level: Application             REF:    143

OBJ:    Discuss the relationship between informatics and quality health care

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Safe and Effective Care Environment

3. A nursing student is working on his clinical assignment. He knows that he must maintain patient confidentiality. Which of the following is acceptable for him to write on the clinical care plan that he will give to his instructor?

ANS:   D

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: Application             REF:    143

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

MSC:   Client Needs: Safe and Effective Care Environment

4. Which of the following agencies have standards that require a nurse’s documentation to be within the context of the nursing process?

ANS:   C

The Joint Commission standards require that a nurse’s documentation be within the context of the nursing process, including evidence of patient and family teaching and discharge planning (TJC, 2008b). 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: Knowledge             REF:    144

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

MSC:   Client Needs: Safe and Effective Care Environment