Chapter 09 Informatics and Documentation

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Chapter 09  Informatics and Documentation

 

 

Complete Chapter Questions And Answers
 

Sample Questions

 

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?
A.
Cost of care per patient day
B.
Number of registered nurses on staff
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.

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:
A.
“I’m sorry; you will have to wait until I am done with my documentation to look at the chart.”
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 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?
A.
Patient room number
B.
Patient date of birth
C.
Patient medical record number
D.
Patient nursing diagnosis

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?
A.
Centers for Disease Control and Prevention
B.
World Health Organization
C.
The Joint Commission
D.
Public Health Department

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

5. Practitioners from many disciplines use the medical record to document data. The most important purpose of the medical record is to:
A.
invoice the patient or insurance company for reimbursement.
B.
protect the clinician in case of a malpractice suit.
C.
ensure everyone is working toward a common goal of providing safe care.
D.
contribute to a databank for medical and nursing research.

ANS: C
The overall purpose of the medical record is to ensure all health team members are working toward a common goal of providing safe, effective, continuity of care.

PTS: 1 DIF: Cognitive Level: Application REF: 144
OBJ: Discuss the relationship between informatics and quality health care
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment

 

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