EHRs and Info Management
This is not considered an advantage of EHRs, even though it may occur as a byproduct of increased tech exposure.
What is increased technology awareness?
This communication style is characterized by using sarcasm, indirect resentment, and subtle hostility.
What is passive-aggressive?
This is not classified as a sentinel event: a near miss with an allergy prescription canceled before administration.
What is a near miss event?
A nurse may access records of clients in the facility only if this condition is met.
What is they are actively caring for the client?
In SOAP charting, pale and diaphoretic skin belongs here—.
What is assessment?
Nurses frequently report that EHR documentation does this to direct client care time, contrary to one common misconception.
What is decrease it?
This is the least therapeutic technique when a client expresses strong emotions about a new colostomy.
What is offering sympathy?
During time-out, asking the client to read their ID bracelet is incorrect; the proper action is this instead.
What is state their full name while the nurse reads the bracelet?
Sharing client info with others who have a similar diagnosis, even without identifying details, violates this.
What is HIPAA / client confidentiality?
Nitroglycerin 0.3 mg SL administered for chest pain is documented in this SOAP component
What is plan?
While EHRs include insurance information for billing purposes, this specific item is not part of the client’s electronic health record itself.
What is billing payments / actual payment records?
For a client with a cognitive disorder, including this would impair learning: abstract imagery, medical slang, or background TV noise
What is any of those—but specifically medical slang or abstract imagery?
For suicide precautions in a nonpsychiatric facility, this observation frequency is required—not 12-hour checks.
What is round-the-clock / 24-hour / continuous 1:1 observation?
This action is not permitted even with family: sharing record info without the client’s expressed permission.
What is sharing with immediate family members?
This documentation method is most appropriate when the goal is to document only unexpected findings related to the client’s condition.
What is Charting by exception
This is the primary reason information management technology improves client safety during medication administration.
What is decreasing human errors?
The psychomotor domain is best evaluated by this action after demonstrating walker use.
What is return demonstration / asking the client to perform the skill?
List four examples of health care-associated infections (HAIs) and one that is not an HAI.
What are correct: ventilator-associated pneumonia, catheter-associated UTI, surgical site infection, central-line bloodstream infection; not an HAI: Pneumonia that develops within the first 48 hours of hospital admission ?
Co-signing nurses’ notes is not a purpose of documentation; providers co-sign these instead
What are prescriptions / orders they have prescribed?
Identify the one incorrect legal guideline for documentation among these: can be used in court, must be timely/organized/accurate, includes nurse interpretation, shared with all facility employees, must be complete.
What is “includes nurse interpretation” or “shared with all facility employees”?
Name two challenges of EHRs that require flexibility from caregivers and can temporarily disrupt workflow.
What are frequent technology updates and required system changes?
Identify the domain (cognitive, affective, psychomotor) for each:
What is 1. cognitive, 2. affective, 3. cognitive, 4. psychomotor?
A client death from an infection following hip surgery qualifies as this type of unexpected occurrence.
What is a sentinel event?
Name the three correct legal documentation standards and the two incorrect ones from standard teaching.
What are correct: used in court, accurate/complete/timely/organized, compliant with state/federal agencies; incorrect: includes nurse interpretation, shared facility-wide?
According to ANA standards, this phrase should be revised because it reflects opinion rather than fact: “The client seems to be more agitated…”
What is “seems to be” / opinion-based language?