chapter 26: informatics and documentation

Question 1

documentation

Answer 1

• vital aspect of nursing
• must document all care provided

nursing documentation systems

• reflect currect standards of nursing practice and minimize the risk of errors
• flexible to allow members of the health care team to efficiently document and retrieve clinical data, track pt. outcomes, ad facilitate continuity of care

Question 2

purpose of health care record

Answer 2

• interprofessional communication
• legal record of care provided
• justification for financial billing and reimbursement of care
• auditing, monitoring, evaluation of care
• education and research

Question 3

interprofessional communication within the medical record

Answer 3

• quality of pt. care depends on your ability to communicate with other members of team
• when a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or ommissions in care often occur

Question 4

communication within the medical record

Answer 4

legal documentation
- accuracy is one of the best defenses for legal claims

reimbursements
- clarifies treatment rendered

auditing and monitoring
- improved quality of care

education
- helps anticipate care needed for the pt.

research

Question 5

what did HITECH establish?

Answer 5

provisions to promote the meaningful use o health info technology to improve the quality and value of health care

Question 6

what will implementing EHR across the health care system do

Answer 6

decrease costs and improve the quality of pt. care

Question 7

EHR

Answer 7

attributes, components and advantages

Question 8

legal risk of electronic documentation

Answer 8

• combination of logical and physical restrictions to protect info
• computers in restricted areas
• privacy filters

Question 9

disposing of info

Answer 9

• safeguard any info that is printed
• destroy when no longer needed
• de-identify all pt. data
• special considerations for faxing

Question 10

guidelines for quality documentation

Answer 10

factual 
accurate
current
organized 
complete

Question 11

methods of documentation

Answer 11

flow charts
progress notes
charting by exception

Question 12

record-keeping forms within the ehr

Answer 12

• admission nursing history form
• pt. care summary
• care plans
• discharge summary forms

Question 13

documentation communication with providers and unique events

Answer 13

• telephone calls made to a provider: document every phone call you to make to the health care provider
• telephone and verbal orders: use of VOs is discouraged except in urgent or emergent situations
• incidence or occurrence reports: not consistent with the routine, expected care of a pt. or the standard procedures in place on a health care unit within an agency

Question 14

acuity rating systems

Answer 14

• determine the hours of care and number of staff required for a given of pt. every shift or every 24 ours
• based on type and number of nursing interventions required by a pt. over 24-hr period

Question 15

acuity level

Answer 15

the classification used to compare one or more pt to another group of pt.

Question 16

documentation in the long term health care setting

Answer 16

• documentation is governed by individual state regulation, tjc and cms
• CMS: mandates use of the RAI, including the MDS and CAA

Question 17

documentation in the home health care setting

Answer 17

• medicare has specific guidelines to establish eligibility for home care reimbursements
• documentation is the quality control and the justification for reimbursement
• two different data sets set to document clinical assessments and care provided
  - OASIS
  - Omaha system

Question 18

case management

Answer 18

incorporates an interprofessional approach to delivery and documentation of pt. care

Question 19

critical pathways

Answer 19

interprofessional care plans that identify pt problems, key interventions, and expected outcomes within an established time frame

Question 20

variances

Answer 20

unexpected outcomes, unmet goals, and interventions not specified within a critical pathway

Question 21

informatics and information management in health care

Answer 21

• health care info system
• clinical information system
• nursing clinical info systems
• clinical decision support system

Question 22

nursing informatics

Answer 22

integrates nursing science, computer science, and information science to manage and communicate data, info, knowledge, and wisdom in nursing and informatics practice