Informatics and Documentation

1.A nurse works at a health care organization that is accredited by The Joint Commission. What is the best method for this health care organization to demonstrate that it is providing quality patient care?

a.
Cost of care per patient day
b.
Number of registered nurses
c.
Absence of sentinel events
d.
Documentation audits

ANS: D

Regulations from agencies such as The Joint Commission and the Centers for Medicare and Medicaid Services require health care institutions to monitor and evaluate the quality and appropriateness of patient care. Typically, such monitoring and evaluations occur through the auditing of information health care providers document in patient records. It does not include cost of care per patient day, number of RNs, nor absence of sentinel events.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 163 OBJ: Identify key reasons for reporting and recording patient care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care

2.A registered nurse is caring for an older adult patient with lung cancer. The daughter, who is also a nurse, asks to see the chart. What is the nurse’s best response?

a.
“Come with me and we will look at it together.”
b.
“I’m sorry; this information is confidential.”
c.
“Let me ask my supervisor if it is okay.”
d.
“You should know better than to ask me that.”

ANS: B

Do not disclose information about patients’ status to other patients, family members (unless granted by the patient), or health care staff not involved in their care. Looking at it together is not acceptable because confidentiality would be broken. Asking a supervisor is inappropriate because the nurse should already know the legalities for confidentiality. Saying, “You should know better than to ask me that” is inappropriate and condescending.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:163

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

3.A nursing student is working on a clinical assignment. Which information is acceptable for the student to write on the clinical care plan that will be given to the instructor?

a.
Patient room number
b.
Patient date of birth
c.
Patient medical record number
d.
Patient nursing diagnosis

ANS: D

The nursing diagnosis is acceptable information to give to a nursing instructor. To further maintain confidentiality and protect patient privacy, make sure written materials used in student clinical practice do not have patient identifiers, such as room number, date of birth, medical record number, or other identifiable demographic information.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:163

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Planning

MSC: NCLEX: Management of Care

4.A nurse is working in an agency with standards that require a nurse’s documentation to be within the context of the nursing process. The nurse is working for which agency?

a.
Centers for Disease Control and Prevention accredited hospital
b.
World Health Organization hospital
c.
The Joint Commission accredited hospital
d.
Agency for Healthcare Research and Quality hospital

ANS: C

The Joint Commission standard for record of care, treatment, and services requires that your documentation be within the context of the nursing process, including evidence of patient and family teaching and discharge planning. Other standards include those directed by state and federal regulatory agencies such as HIPAA, as enforced through the Department of Justice, and the Centers for Medicare and Medicaid Services.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:164

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation

MSC: NCLEX: Management of Care

5.Which information indicates the nurse has a correct understanding of the purpose of a patient’s medical record?

a.
To invoice the nurse for reimbursement
b.
To protect the patient in case of a malpractice suit
c.
To ensure everyone is working toward a common goal of providing safe care
d.
To contribute to a worldwide databank for trends in health care

ANS: C

The medical record helps to ensure that all health team members are working toward a common goal of providing safe and effective care. Documentation can be used for reimbursement but it is not to invoice the nurse, but to invoice patients and/or insurance companies. It protects the clinician in cases of a malpractice suit, not the patient. It does not contribute to a worldwide databank for trends in health care, but it can be used for medical or nursing research.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 164 OBJ: Identify key reasons for reporting and recording patient care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care

6.A nurse is frustrated about the lack of staffing for the shift. When one of the patients fell and broke a hip, the nurse documented the incident in the patient’s chart. Which entry is the bestway that the nurse should document what happened?

a.
“Patient stated that fell while going to the bathroom. Physician notified.”
b.
“Nobody available to answer call bell; patient got up on own and fell.”
c.
“Patient fell because of unsafe staffing levels on unit.”
d.
“Patient waited as long as possible but nobody there to help and fell.”

ANS: A

Charting should be factual. Patient stated that fell is the most factual. Do not write retaliatory or critical comments about patient or care by other health care professionals. Statements that are retaliatory or critical can be used as evidence for nonprofessional behavior or poor quality of care. Nobody available to answer call bell, fell because of unsafe staffing levels, or nobody to help are all retaliatory or critical comments and should not be used.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:165

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation

MSC: NCLEX: Management of Care

7.A registered nurse is documenting patient assessments. Which documentation written by the nurse is most clear?

a.
“Seems comfortable at this time.”
b.
“Is asleep, appears not to be experiencing pain.”
c.
“Apparently is not in pain because patient didn’t rate it high on the scale.”
d.
“States pain is a 2 on a 0 to 10 scale.”

ANS: D

States pain is a 2 is factual. To be factual, avoid words such as appears, seems, or apparently because they are vague and lead to conclusions that cannot be supported by objective information.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:166

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation

MSC: NCLEX: Management of Care

8.A patient states that he or she is experiencing pain in the lower back. What is the best way for the nurse to document this subjective information?

a.
“Seems back is hurting.”
b.
“States ‘My lower back hurts.’”
c.
“Grimaces when moving; I believe patient has lower back pain.”
d.
“Appears to be uncomfortable with lower back pain.”

ANS: B

The only subjective data included in a record are what the patient says. Write subjective information with quotation marks, using the patient’s own words. For example, a patient’s statement of “My lower back hurts” is subjective and acceptable documentation. Seems and appears should be avoided. A factual record contains descriptive, objective information about what you see, hear, feel, and smell, not the nurse’s opinions.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:166

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation

MSC: NCLEX: Management of Care

9.Which documentation by the nurse best describes patient data?

a.
“Moderate amount of clear yellow urine voided.”
b.
“Voided 220 mL clear yellow urine.”
c.
“A small amount of urine voided into absorbent pad.”
d.
“Patient incontinent of urine.”

ANS: B

The use of precise measurements makes documentation more accurate. For example, documenting “Voided 450 mL clear urine” is more accurate than “Voided an adequate amount.” Small and moderate are not as accurate as precise measurement. Patient incontinent of urine does not tell how much and although accurate is not as accurate as a precise measurement.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:167

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation

MSC: NCLEX: Management of Care

10.Which entry by the nurse demonstrates the most accurate and safe documentation of patient care?

a.
“Sm. amt. of emesis.”
b.
“150 mL of cloudy dark yellow urine.”
c.
“Had a good day.”
d.
“Looks bad.”

ANS: B

150 mL of cloudy dark yellow urine is the best. The use of precise measurements makes documentation more accurate. To avoid misunderstandings and promote patient safety, write out any abbreviations that are possibly confusing. Avoid using generalized, empty phrases, such as “had a good day.” Be objective and factual; do not use “looks bad” because it is vague and too general.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:166 | 167

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation

MSC: NCLEX: Management of Care

11.Which documentation by the nurse is most appropriate?

a.
“The patient states would except moving to a semi-private room.”
b.
“Developed aspiration pneumonia due to dysphasia.”
c.
“Bruise noted on right side over fractured abdimin.”
d.
“Right jugular vein distended.”

ANS: D

Right jugular vein distended is the only entry without spelling errors. Correct spelling demonstrates competency and attention to detail. Misspelled words lead to confusion. For example, often words sound the same but have different meanings such as accept and except or dysphagia and dysphasia. Misspellings and incorrect use of terms alters the intended meaning. Not only is abdomen misspelled, but an abdomen cannot be fractured.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:167

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation

MSC: NCLEX: Management of Care

12.A nurse is documenting the last entry for the day. It is 3:15 PM and the agency uses military time. Which time should the nurse enter?

a.
315
b.
0315
c.
1315
d.
1515

ANS: D

3:15 is 1515 in military time (1200 + 315 = 1515). The military clock begins at 1 minute after midnight as 0001 and ends with midnight at 2400. For example, 10:22 AM is 1022 military time; 1:00 PM is 1300 military time.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:168

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

13.Which information by a nurse indicates more teaching is needed about The Joint Commission’s requirements for writing plans of care?

a.
A care plan must be developed for patients in a clinic.
b.
A care plan must be developed for patients in an acute care hospital.
c.
A care plan must be developed for patients in a rehabilitation agency.
d.
A care plan must be developed for patients in an extended care facility.

ANS: A

The question indicates the nurse needs more teaching and The Joint Commission does not require a care plan for clinic patients. The Joint Commission standards require that a care plan, also called a “plan of care,” be developed for all patients on admission to acute, subacute, rehabilitation, or extended care agencies.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:169

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Evaluation

MSC: NCLEX: Management of Care

14.A registered nurse recently went to work for a health care organization that uses the SOAP format for documentation. The nurse charts the following: Discuss alternatives for pain control. Which component of SOAP did the nurse chart?

a.
S
b.
O
c.
A
d.
P

ANS: B

Discuss alternatives for pain control is a Plan. SOAP is an acronym for the following:

S: Subjective data (verbalizations of the patient)

O: Objective data (data that are measured and observed)

A: Assessment (diagnosis based on the subjective and objective data)

P: Plan (what the caregiver plans to do)

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 169 | 170 OBJ: Compare different methods used in documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

15.A nurse is told during orientation that the organization is very patient focused and that it uses a documentation system with the acronym PIE. What will the nurse be charting?

a.
Problem, intervention, evaluation
b.
Patient, interview, evaluation
c.
Population, intervention, encourage
d.
Plan, interview, enhance

ANS: A

PIE is an acronym for problem, interventions, evaluation as follows:

P: Problem or nursing diagnosis applicable to patient

I: Interventions or actions taken

E: Evaluation of the outcomes of nursing interventions

The PIE format simplifies documentation by unifying the care plan and progress notes into a complete record. PIE does not include patient, population, or plan. It also does not have encourage or enhance.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 169 | 170 OBJ: Compare different methods used in documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

16.A new registered nurse is working on a pediatric unit in a large teaching hospital that uses focus charting with the acronym DAR. What will the nurse be charting?

a.
Data, assessment, reaction
b.
Data, assessment, recommendation
c.
Data, actions, response
d.
Data, actions, recovery

ANS: C

Each entry includes data, actions, and patient response (DAR) for the particular patient situation. Focus charting (DAR) is a unique narrative format in that it places less emphasis on patient problems and instead focuses on patient concerns such as a sign or symptom, a condition, a behavior, or a significant event. There are no reaction, recommendation, recovery, or assessment in DAR.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 169 | 170 OBJ: Compare different methods used in documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

17.A registered nurse recently changed jobs and is now working in home health. What must the nurse chart to obtain reimbursement from Medicare, Medicaid, and private insurance companies?

a.
Patient’s response to care
b.
Whether patient had a good or bad day
c.
Whether family liked nurse or not
d.
Patient’s number of marriages

ANS: A

When you provide home care, your documentation must specifically address the category of care and your patient’s response to care. Good or bad day is not factual or objective information. Whether family liked nurse or not and the number of marriages does not affect reimbursement.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:172

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

18.The nurse manager of a large medical unit in a busy urban teaching hospital reviews the unit trends for staffing, which are determined by an acuity system. The nurse manager notices that the acuity level is high. What should the nurse manager do?

a.
More staff may be needed.
b.
Talk to the patients.
c.
Less staff may be needed.
d.
Talk to the families.

ANS: A

A high acuity means more staff may be needed. An acuity recording system determines the hours of care for a nursing unit and the number of staff required to care for a given group of patients. A low acuity would mean less staff is needed. Talking to the patients or family is not related to the acuity level.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:171OBJ:Identify common record-keeping forms.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

19.A nurse began working at a local hospital and learned that the hospital had just instituted a “hand-off” protocol. What will the nurse be doing?

a.
Performing transfer reports
b.
Completing IV fluid flow sheets
c.
Using standardized care plans
d.
Reviewing laboratory reports

ANS: A

Examples of hand-off reports include change-of-shift reports and transfer reports. A hand-off report occurs any time one health care provider transfers care of a patient to another health care provider. The purpose of hand-off reports is to provide better continuity and individualized care for patients. Flow sheets are part of the permanent health record and provide a quick and easy reference for assessing changes in a patient’s status. Standardized care plans, based on institution standards of nursing practice, are preprinted established guidelines of care for patients with similar health problems. The laboratory submits a written report providing the results of diagnostic tests.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:172

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

20.A nurse is using SBAR and tells the primary health care provider that the abdomen is distended and firm with a pain rating of 8 on a 0-10 scale. Which component of SBAR did the nurse communicate?

a.
S
b.
B
c.
A
d.
R

ANS: C

For assessment (A) data include significant findings in your head-to-toe physical assessment, recent vital signs, current treatment measures, restrictions, recent laboratory results and diagnostics, and pain status. Some institutions use SBAR, an acronym that stands for situation, background, assessment, and recommendation. SBAR standardizes telephone communication of significant events or changes in a patient’s condition. Therefore it is a communication strategy designed to improve patient safety. When describing the situation (S), you include the admitting and secondary diagnoses and the problem your patient is having as the current issue. Background (B) information includes pertinent medical history, previous laboratory tests and treatments, psychosocial issues, allergies, and current code status. Provide your recommendation (R), in which you suggest a plan of care and request orders and other needs to be addressed.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 174 OBJ: Compare different methods used in documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

21.A nurse records the following at 1800: patient states that the abdominal pain is worse now than last night—Betty Smith, RN. The nurse is using which type of charting?

a.
PIE documentation
b.
SOAP documentation
c.
Narrative charting
d.
Charting by exception

ANS: C

Narrative charting uses a storylike format to document information specific to patient conditions and nursing care. PIE charting focuses on problem, intervention, and evaluation. SOAP documentation addresses subjective data, objective data, assessment, and the plan. Charting by exception reduces the time required to complete documentation, using a flow sheet to indicate normal findings or routine interventions.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 170 OBJ: Compare different methods used in documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

22.A nurse completes an incident/occurrence report on a patient who fell while walking in the hallway. The nurse completes this report for what purpose?

a.
To exchange information among health care members
b.
To provide information about patients on one unit to another
c.
To prevent a legal lawsuit from the patient
d.
To aid in the hospital’s quality improvement program

ANS: D

Incident reports are an important part of quality improvement. The overall goal is to identify changes needed to prevent future reoccurrence. A report is an exchange of information between health care members. Transfer reports involve communication of information about patients from one nurse on the sending unit to the nurse on the receiving unit. Occurrence reports do not prevent lawsuits.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:175OBJ:Identify common record-keeping forms.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control

23.After a nurse receives a medication telephone order for a patient, what is the proper action?

a.
Withholding the medication until the physician or health care provider signs the order
b.
Verifying the physician’s or health care provider’s order with the pharmacy
c.
Reading it back to the person who gave the order
d.
Clarifying the new medication order with another registered nurse

ANS: C

The nurse receiving a verbal order or telephone order writes down the complete order or enters it into the computer as it is being given. Then the nurse reads it back, called read-back, and receives confirmation from the person who gave the order. The medication will still be given because in most institutions the health care provider has 24 hours to sign the order. Verification is in the read back with the person who ordered the medication, not with pharmacy or another nurse.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:175

OBJ: Describe methods for interdisciplinary communication within the health care team.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control

24.A nurse is giving a change-of-shift report. Which action should the nurse take?

a.
Exchange judgments made about the patient’s attitudes.
b.
Include a description of how to perform procedures.
c.
Provide a concise and organized description of the patient’s normal findings.
d.
Make walking rounds with the nurse coming on duty to review the patient’s status and needs.

ANS: D

A change-of-shift report is a hand-off and provides information to ensure continuity and individualized care for patients. Walking rounds allow the nurse to obtain immediate feedback when questions arise about a patient’s plan of care. Walking rounds are one type of shift report used by health care facilities. Report elements should not include normal findings or routine information retrievable from other sources or derogatory or inappropriate comments about a patient or family. A description of how to perform procedures is located in a policy and procedure manual.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:174

OBJ:Describe guidelines for effective documentation and reporting in a variety of health care settings.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

25.A nurse is using critical pathways to care for a patient. Which area will the nurse address according to the pathway?

a.
Activity
b.
Nursing diagnosis
c.
Times to chart
d.
Admission form

ANS: A

Critical pathways are usually organized according to categories such as activity, diet, treatments, protocols, and discharge planning. The case management plan incorporates critical pathways, which standardize practice and improve interdisciplinary coordination. The admission form allows the admitting nurse to make a thorough assessment (e.g., biographical data, physical and psychosocial/cultural assessment, and review of health risk factors) and identify relevant nursing diagnoses or problems for the patient’s care plan. Nursing diagnoses are used in the nursing process, not with critical pathways. Times to chart are not addressed in the critical pathway.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 170 OBJ: Compare different methods used in documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

26.A nurse is preparing a discharge summary. Which item should the nurse include?

a.
Provision for follow-up care
b.
Patient status at admission
c.
Standardized nursing care plan
d.
Detailed description of nursing procedures

ANS: A

A nursing discharge note needs to cover the reason for hospitalization, procedures performed, care, treatment, and services provided, patient status at discharge, information provided to the patient and family, and provisions for follow-up care. Patient status at discharge, not admission, is included. Standardized nursing care plans are based on the institution’s standards of nursing practice and are preprinted established guidelines of care for patients with similar health problems. Detailed descriptions of nursing procedures are located in policy and procedure manuals, but not in a discharge summary.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:171OBJ:Identify common record-keeping forms.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

27.A nurse is teaching the staff about informatics and describing the key concepts. Which information should the nurse include during the teaching session?

a.
Wisdom
b.
Charting
c.
Assessment
d.
Evaluation

ANS: A

The concepts are data, information, knowledge, and wisdom. Wisdom answers the “why.” Charting is documentation. Assessment and evaluation are included in the nursing process.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:176

OBJ: Discuss the relationship between informatics and quality health care.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

28.A nurse is using a computer to locate and review laboratory test results, and chart and order sterile supplies. What type of system is the nurse using?

a.
Clinical information system
b.
Computerized provider order entry system
c.
Administrative information system
d.
Clinical decision support system

ANS: A

Clinical information systems can be used by any clinician, including nurses, to plan, implement and evaluate care and can be used for charting, reviewing laboratory test results, and ordering sterile supplies. Administrative information systems comprise databases such as payroll, financial, and quality assurance systems. Computerized provider order entry (CPOE) refers to a process by which the health care provider directly enters orders for patient care into the hospital information system. The clinical decision support system (CDSS) links the nurse to the latest evidence-based practice guidelines at the point of care.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 177 OBJ: Discuss advantages of computerized documentation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

29.Which action should the nurse take when handling and disposing of patient information?

a.
Keep patient information to take home for disposal.
b.
Use programmed speed-dial keys when faxing.
c.
Throw hand-written notes about the patient in the trash.
d.
Place fax machines in a public place.

ANS: B

Use programmed speed-dial keys when faxing to eliminate the chance of a dialing error and misdirected information. Place fax machines in a secure area, not a public area. Patient information must be shredded, and taking patient information home or throwing in the trash is breaking confidentiality.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:179-180

OBJ: Discuss advantages and disadvantages of standardized documentation forms.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

MULTIPLE RESPONSE

1.Which information by the staff indicates teaching by the nurse was successful for the purposes of documentation? (Select all that apply.)

a.
To aid in clinical research
b.
To maintain a legal and financial record of care
c.
To include a step-by-step description of how to perform procedures
d.
To evaluate quality process and performance improvement
e.
To communicate patient needs and progress toward meeting outcomes

ANS: A, B, D, E

Documentation serves multiple purposes, including communication, legal documentation, reimbursement, education, research, and quality process and performance improvement. Step-by-step description of how to perform procedures is in a policy and procedure manual, not a chart.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 164 | 166 OBJ: Identify key reasons for reporting and recording patient care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care

2.Which benchmarks will indicate to the nurse that the agency has computerized information systems that demonstrate “meaningful use”? (Select all that apply.)

a.
Improves quality and safety
b.
Improves patient compliance
c.
Improves care coordination
d.
Improves public health
e.
Improves hospital’s reputation

ANS: A, C, D

Meaningful use refers to the level with which information technology is available and used to support clinical decision making to improve quality, safety, and efficiency; reduce health disparities; engage patients and families in their health care; improve care coordination; improve population and public health; and maintain privacy and security. Patient compliance and hospital’s reputation are not benchmarks for the mandates from the Patient Protection and Affordable Care Act.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:168-169

OBJ: Discuss the relationship between informatics and quality health care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care

3.Which guidelines must the nurse follow to appropriately manage electronic patient information? (Select all that apply.)

a.
Never share passwords with co-workers.
b.
Only the supervisor should have the nurse’s password and it should be stored in a protected place.
c.
Leave the computer terminal unattended when logged on.
d.
Avoid leaving patient information displayed on a computer where others can see it.
e.
Keep the same password for as long as the nurse works at the agency.

ANS: A, D

To protect patient confidential data the nurse should never share passwords and should change them as directed. Avoid leaving patient information displayed on a computer where others can see it. Avoid leaving the computer terminal unattended when logged on. A good system requires frequent changes in personal passwords to prevent unauthorized persons from accessing and tampering with records.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:169

OBJ: Discuss advantages and disadvantages of standardized documentation forms.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care