Chapter 26: Informatics and Documentation

A nursing professional in a hospital setting engaging with electronic health records, demonstrating the importance of informatics in patient care.

Informatics and Documentation Quiz

Test your knowledge on the critical aspects of informatics and documentation in nursing with this comprehensive quiz. Designed for nursing students and professionals alike, this quiz covers essential topics such as patient information exchange, healthcare documentation protocols, and legal responsibilities in patient care.

31 multiple-choice and checkbox questions
Focused on real-world nursing scenarios
Enhance your understanding of HIPAA and patient privacy

31 Questions8 MinutesCreated by CaringNurse512

1. A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene?

A. Reading the patient’s plan of care

B. Reviewing the patient’s medical record

C. Sharing patient information with another student

D. Documenting medication administered to the patient

2. A nurse exchanges information with the oncoming nurse about a patient’s care. Which action did the nurse complete?

A. A verbal report

B. An electronic record entry

C. A referral

D. An acuity rating

3. A nurse is auditing and monitoring patients’ health records. Which action is the nurse taking?

A. Determining the degree to which standards of care are met by reviewing patients’ health records

B. Realizing that care not documented in patients’ health records still qualifies as care provided

C. Basing reimbursement upon the diagnosis-related groups documented in patients’ records

D. Comparing data in patients’ records to determine whether a new treatment had better outcomes than the standard treatment

4. After providing care, a nurse charts in the patient’s record. Which entry will the nurse document?

A. Appears restless when sitting in the chair.

B. Drank adequate amounts of water

C. Apparently is asleep with eyes closed

D. Skin pale and cool.

5. A nurse has provided care to a patient. Which entry should the nurse document in the patient’s record?

A. Status unchanged, doing well.

B. Patient seems to be in pain and states, “I feel uncomfortable.”

C. Left knee incision 1 inch in length without redness, drainage, or edema.

D. Patient is hard to care for and refuses all treatments and medications. Family is present.

6. Which action by a novice nurse will cause the preceptor to provide follow up instructions?

A. Documents descriptively.

B. Charts consecutively on every other line

C. Ends each entry with signature and title.

D. Uses quotations to note patients’ exact words.

7. Which action can the nurse take legally when charting on a patient’s record?

A. Charts in a legible manner.

B. States the patient is belligerent.

C. Writes entry for another nurse.

D. Uses correction fluid to correct error

8. A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse access?

A. Electronic medical record

B. Electronic health record

C. Electronic charting record

D. Electronic problem record

9. A nurse has instructed the patient regarding the proper use of crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the “I” in PIE charting?

A. Patient went up and down stairs

B. Demonstrated use of crutches

C. Used crutches with no difficulties

D. Deficient knowledge related to never using crutches

10. A nurse wants to find the daily weights of a hospitalized patient. Which resource will the nurse consult?

A. Database

B. Progress notes

C. Patient Care Summary

D. Graphic record and flow sheet

11. A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?

A. Add this data to the problem list.

B. Focus chart using the DAR format.

C. Document the variance in the patient’s record.

D. Report a positive variance in the next interdisciplinary team meeting

12. A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient?

A. Upon admission

B. Right before discharge

C. After the congestion is treated

D. When the primary care provider writes the order

13. A patient is being discharged home. Which information should the nurse include?

A. Acuity level

B. Community resources

C. Standardized care plan

D. Signature for verbal order

14. A nurse developed the following discharge summary sheet. Which critical information should the nurse add? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge

A. Clinical decision support system

B. Admission nursing history

C. Mode of transportation

D. SOAP notes

15. A home health nurse is preparing for an initial home visit. Which information should be included in the patient’s home care medical record?

A. Nursing process form

B. Step-by-step skills manual

C. A list of possible procedures

D. Reports to third-party payers

16. A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing?

A. A minimum data set

B. An admission assessment and acuity level

C. A focused assessment/specific body system

D. An intake assessment form and auditing phase

17. A nurse is charting. Which event is critical for the nurse to document?

A. The patient had a good day with no complaints.

B. The family is demanding and argumentative.

C. The patient received a pain medication

D. The family is poor and had to go on welfare.

18. A nurse is completing an Outcome and Assessment Information Set (OASIS) data set on a patient. The nurse works in which area of patient care?

A. Home health

B. Intensive care unit

C. Skilled nursing facility

D. Long-term care facility

19. A nurse is preparing to document a patient who has reported chest pain. Which information provided by the patient is critical for the nurse to include?

A. “My family doesn’t believe I’m in pain.”

B. Pupils equal and reactive to light.

C. Had poor results from the pain medication

D. Reports sharp pain of 8 on a scale of 1 to 10

20. Which action will the nurse take when taking a telephone order?

A. Print out a copy of the order once entered into the electronic health record

B. Read back the order as written to the health care provider for verification.

C. Ask that another registered nurse listen to the call over an extension line.

D. Verify that the health care provider will write the order within 24 hours.

21. A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?

A. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.

B. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back.

C. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.

D. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN.

22. A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up?

A. To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice

B. A nurse needs to know how to find, evaluate, and use information effectively

C. If a nurse has computer competency, the nurse is competent in informatics.

D. Nursing informatics is a recognized specialty area of nursing practice.

23. A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using?

A. Clinical decision support system

B. Nursing process design

C. Critical pathway design

D. Computerized provider order entry system

24. A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take?

A. Use the same password all the time.

B. Share password with only one other staff member

C. Print out and review computer nursing notes at home.

D. Chart on the computer immediately after care is provided.

25. Which entry will require follow-up by the nurse manager? 0800 Patient states, “Fell out of bed.” Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, “Did not pass out.” Assisted back to bed. Nurse call system within reach. Bed monitor on. -------------------Jane More, RN 0810 Notified primary care provider of patient’s status. New orders received. -------------------Jane More, RN 0815 Portable x-ray of L hip taken in room. States, “I feel fine.” -------------------Jane More, RN 0830 Incident report completed and placed on chart. -------------------Jane More, RN

A. 0800

B. 0810

C. 0815

D. 0830

26. A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement?

A. Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.

B. Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, “felt better.” Finally, patient had no complaints.

C. Breathing without difficulty. Sitting up in bed watching TV. Had a good day

D. Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.

27. A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session?

A. Home health, long-term care, and hospital nurses’ documentation can affect reimbursement for health care.

B. A clinical information system must be installed by 2014 to obtain health care reimbursement.

C. A “near miss” helps determine reimbursement issues for health care.

D. HIPAA is the basis for establishing reimbursement for health care.

28. A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe?

A. Varied clinical databases

B. Reduced errors of omission

C. Increased hospital costs

D. More time to read charts

1. Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)

A. Writes the patient’s room number and date of birth on a paper for school.

B. Prints/copies material from the patient’s health record for a graded care plan

C. Reviews assigned patient’s record and another unassigned patient’s record.

D. Gives a change-of-shift report to the oncoming nurse about the patient.

E. Reads the progress notes of assigned patient’s record.

F. Discusses patient care with the hospital volunteer.

2. A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.)

3. A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)

A. Bypass the firewall

B. Implement an automatic sign-off.

C. Create a password with just letters.

D. Use a programmed speed-dial key when faxing

E. Impose disciplinary actions for inappropriate access

F. Shred papers containing personal health information (PHI).

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Chapter 26: Informatics and Documentation

Informatics and Documentation Quiz

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