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Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which are accurate statements about EHR?
- A. It is a record of the patient's interactions with the primary care doctor, but not with specialists.
- B. It is a record of an individual's lifetime health information, easily updated and transferable.
- C. It has built-in security and confidentiality, so nurses do not have to take any additional precautions.
- D. The nurse is only supposed to access the records of the patients that he or she cares for, not every patient on the nursing unit.
- E. It is only available on hand-held computers.
Correct Answer: B,D
Rationale: EHR is a lifetime health record (B) and nurses should only access assigned patients' records (D). A is false as it includes specialists, C is false as precautions are needed, and E is false as EHR is not limited to hand-held devices.
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Indicate whether the following statements are True (T) or False (F). In charting by exception, normal findings are not charted and checklists are used for routine care.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True (T): Charting by exception focuses on abnormal findings, using checklists for routine care.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. When documenting with focus charting, which acronym is generally used?
- A. SOAP
- B. SOAPIER
- C. PIE
- D. DAR
Correct Answer: D
Rationale: Focus charting uses the DAR (Data, Action, Response) acronym (D). SOAP (A), SOAPIER (B), and PIE (C) are used in other charting methods.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Some of the following documentation phrases include subjective terminology that needs to be changed to objective terminology. Select the phrases with subjective terms and underline the subjective word(s) that need(s) to be changed to objective.
- A. Snored loudly most of night between 0030 and 0530.
- B. Green purulent drainage increased from yesterday. ABD pad has 6' circle of drainage.
- C. Procedure tolerated well.
- D. ADA diet-ate 75% tolerated poorly.
- E. Bouncing foot almost continually. Rubbing hands and flicking finger with thumb at intervals. Verbally denies feeling nervous or anxious.
- F. Got mad while ambulating in the hall.
- G. Has a bad attitude.
Correct Answer: C,D,F,G
Rationale: Subjective terms: 'tolerated well' (C), 'tolerated poorly' (D), 'got mad' (F), 'bad attitude' (G). These should be replaced with objective descriptions. A, B, and E are objective.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following statement(s) regarding a patient's hospital medical record is(are) accurate?
- A. All the information within the chart belongs to the patient.
- B. Access to a patient's medical record is restricted to the physician, the nurse, and the patient.
- C. HIPAA guarantees the patient the right to view his or her own medical record.
- D. The patient may not take the original medical record because it is the property of the hospital.
- E. The medical record belongs to the admitting physician.
- F. The hospital must provide the patient with a written explanation of how the patient's health information will be used.
- G. The patient has the right to a copy of any or all of his or her own medical records.
Correct Answer: C,D,F,G
Rationale: HIPAA ensures patient access to records (C), originals are hospital property (D), hospitals must explain health information use (F), and patients can get copies (G). A is false as information is owned by the hospital, B is false as others may access records, and E is false as records are not owned by physicians.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Guidelines for paper documentation include which of the following?
- A. All documentation for your shift must be signed after you have charted your last entry for the shift.
- B. All documentation must be done in cursive writing.
- C. Charting should be done in blocks of time to reduce the number of unnecessary entries.
- D. The date and time should be included with each entry.
Correct Answer: A,D
Rationale: Paper documentation requires signing at shift's end (A) and including date/time (D). Cursive is not mandatory (B), and block charting (C) is not standard.