The ANA's model for high-quality nursing documentation reflects ________ _________ and includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and retrievability.
What is The nursing process?
100
A longitudinal record of health that includes the information from inpatient and outpatient episodes of health care.
What is electronic health record?
100
Mistaken for the number 0 or 4 or for cc
What is U or u?
100
The use of the Internet to link medical experts with other clinicians, allowing remote consultations with clear video images and high fidelity links.
What is telehealth or telemedicine?
100
The unique ability of a patient to understand and integrate health-related knowledge.
What is health literacy?
200
A document with comprehensive information about a patient's health care encounter, as well as demographic, administrative, and clinical data.
What is the medical record?
200
Allows clinicians to enter orders in a computer that are sent directly to the appropriate department.
What is CPOE? or computerized provider order entry.
200
Mistaken for IV or the number 10.
What is IU or international unit?
200
A broad academic field encompassing artificial intelligence, cognitive science, computer science, information science, and social science.
What is informatics?
200
Effective _________ _________ is key to health promotion and wellness.
What is patient education?
300
A record of one episode of care, such as an inpatient or an outpatient appointment.
What is electronic medical record?
300
Adoption of an EHR system produces major _______ ________ through gains in productivity and error reduction.
What is cost savings?
300
Use instead daily, every other day.
What is QD or QOD?
300
The "Future of Nursing: Leading Change, Advancing Health" emphasizes that nurses use technology resources that "require skills in analysis and synthesis to improve the quality and effectiveness of care".
What is the IOM (Institute of Medicine) report?
300
__________ is imparting knowledge or giving instruction, whereas _____________ is acquiring knowledge or skills through instruction or experience.
What is teaching and learning?
400
The medical record is the ___________ documentation of care provided to a patient.
What is the legal documentation?
400
Use of EHRs can reduce ________ space and allow ____________ access by multiple users.
What is storage and simultaneous?
400
Can mean morphine sulfate or magnesium sulfate.
What is MS?
400
Knowledge of computers and the ability to use them efficiently.
What is computer literacy?
400
Nurses need to provide patients with easy-to-understand information and speak in a clear, distinct voice, using short sentences and understandable ______________.
What is terminology?
500
Every note in the medical record must contain a _____, ______, and ___________.
What is date, time and signature?
500
10% of Medicare reimbursement
What is the penalty for not having an EMR?
500
Decimal point is confusing.
What is a trailing zero or lack of leading zero?
500
Identified a set of technology skills needed by all nurses practicing in the 21st century.
What is the TIGER initiative?
500
Nursing diagnoses specifically related to patient education include: ___________________, _____________________________, and_______________.
What is Deficient Knowledge, Readiness for Enhanced Knowledge, and Noncompliance.