Documentation and Informatics Paper Essay

Documentation and Informatics Paper

1. A manager who is reviewing the nurses’ notes in a patient’s
medical record finds the following entry, “Patient is difficult to
care for, refuses suggestion for improving appetite.” Which of
the following directions does the manager give to the staff
nurse who entered the note?
1. Avoid rushing when charting an entry.
2. Use correction fluid to remove the entry.
3. Draw a single line through the statement and initial it.
4. Enter only objective and factual information about the
patient.
2. A new graduate nurse is providing a telephone report to
a patient’s health care provider and accepting telephone
orders from the provider. Which of the following actions
requires the new nurse’s preceptor to intervene? The new
nurse:
1. Uses SBAR (Situation-Background-AssessmentRecommendation) as a format when providing the
report.
2. Gives a newly ordered medication before entering the order
in the patient’s medical record.
3. Reads the orders back to the health care provider after
receiving them and verifies their accuracy.
4. Asks the preceptor to listen in on the phone conversation.
3. As you enter the patient’s room, you notice that he is anxious
to say something. He quickly states, “I don’t know what’s going
on; I can’t get an explanation from my doctor about my test
results. I want something done about this.” Which of the following is the most appropriate documentation of the patient’s
emotional status?
1. The patient has a defiant attitude and is demanding his test
results.
2. The patient appears to be upset with his nurse because he
wants his test results immediately.
3. The patient is demanding and complains frequently about
his doctor.
4. The patient stated that he felt frustrated by the lack of
information he received regarding his tests.
4. You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during
the admission process. The patient states, “I’ve heard a lot
about these HIPAA regulations in the news lately. How will
they affect my care?” Which of the following is the best
response?
1. HIPAA allows all hospital staff access to your medical
record.
2. HIPAA limits the information that is documented in
your medical record.
3. HIPAA provides you with greater control over your personal health care information.
4. HIPAA enables health care institutions to release all of
your personal information to improve continuity
of care.
5. A patient asks for a copy of her medical record. The best
response by the nurse is to:
1. State that only her family may read the record.
2. Indicate that she has the right to read her record.
3. Tell her that she is not allowed to read her record.
4. Explain that only health care workers have access to her
record.

Documentation and Informatics Paper Essay

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