Documentation and EHR
What is the main purpose of the Electronic Health Record (EHR)?
To provide a complete, accurate, and up-to-date record of a patient’s health information.
What are the five steps of the nursing process?
Assessment, Diagnosis, Planning, Implementation, Evaluation.
What is the purpose of the Clinical Judgment Model?
To guide nurses in making safe, evidence-based decisions.
What organization promotes patient safety standards in healthcare?
The Joint Commission.
What is informed consent?
The patient’s right to understand and agree to a treatment before it begins.
What term describes entering data into a patient’s record as events occur?
Charting in real-time.
What is the purpose of the assessment phase?
To collect data about the patient’s health status.
What are the six steps of Tanner’s Clinical Judgment Model?
Noticing, Interpreting, Responding, Reflecting (in-action and on-action).
What are the “Five Rights” of medication administration?
Right patient, right drug, right dose, right route, right time.
What type of law regulates nursing practice?
Administrative law (through Nurse Practice Acts).
What does “PIE” charting stand for?
Problem, Intervention, Evaluation.
What type of diagnosis identifies the patient’s response to a health condition?
Nursing diagnosis.
What happens during the “Noticing” phase?
The nurse recognizes cues and collects relevant patient information.
What does a fall risk assessment identify?
The patient’s likelihood of falling to prevent injury.
What should a nurse do if an error is made in documentation?
Report it immediately and make a single line through the error, with initials and date.
Why is documenting only objective data important in nursing notes?
It prevents bias and maintains accuracy and professionalism.
What is a SMART goal?
Specific, Measurable, Achievable, Relevant, and Time-bound goal.
What is the main goal of “Responding”?
Taking appropriate action based on the interpretation of patient data.
What is the most effective way to prevent infection in healthcare?
Hand hygiene.
What ethical principle means “do no harm”?
Nonmaleficence.
What is the nurse’s legal responsibility when documenting care?
To document promptly, accurately, and truthfully; if not documented, it’s considered not done.
What should a nurse do if goals are not met during the evaluation phase?
Modify the care plan and reassess interventions.
How does reflection improve clinical judgment?
It helps nurses learn from experiences to improve future decision-making.
What is a sentinel event?
An unexpected occurrence involving death or serious injury.
What is the nurse’s responsibility when witnessing unethical behavior?
Report it following facility policy and chain of command.