Exam (elaborations)

Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative Practice, 2nd Edition Test Bank All Chapters

9 views 0 purchase

Course
Nursing

Institution
Chamberlain School Of Nursing

Book
Fundamentals of Nursing

Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative Practice, 2nd Edition Test Bank All Chapters Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative Practice, 2nd Edition Test Bank All ChaptersYoost & Crawford: Fundamentals of Nursing: Active Learn...

[Show more]

Preview 4 out of 385 pages

View example

Uploaded on March 23, 2022
Number of pages 385
Written in 2021/2022
Type Exam (elaborations)
Contains Questions & answers

2nd edition
2nd ed
yoost amp crawford fundamentals of nursing active learning for collaborative practice
yoost amp crawford fundamentals of nursing active learning for collaborative practice

Book Title:Fundamentals of Nursing

Author(s):Barbara L. Yoost, Lynne R. Crawford

Edition:2019
ISBN:9780323508643
Edition:Unknown

Exam (elaborations)
TEST BANK FOR FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLABORATIVE PRACTICE 2ND EDITION, BY BARBARA L YOOST UPDATED A+
Exam (elaborations)
Full Test Bank Fundamentals of Nursing 2nd Edition Yoost Test Bank
Exam (elaborations)
Fundamentals of Nursing 2nd Edition Test Bank Yoost All Chapters (1-42) | A+ ULTIMATE GUIDE

Institution
Chamberlain School Of Nursing
Nursing

Lectfayh

Member since 3 year 102 documents sold

CA$28.22

Added

Add to cart

Add to wishlist

100% satisfaction guarantee
Immediately available after payment
Both online and in PDF
No strings attached

Stuvia.com - The Marketplace to Buy and Sell your Study Material

TEST BANK FOR
FUNDAMENTAL
S OF NURSING
2ND EDITION
BY YOOST

Downloaded
Downloaded
by: LuckyGrades
by: Sophiie
SuperA ||abiekay12@gmail.com
abbiewamalwa@gmail.com
Distribution of this document is illegal

, Stuvia.com - The Marketplace to Buy and Sell your Study Material

Chapter 10: Documentation, Electronic Health Records, and Reporting
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 2nd Edition

MULTIPLE CHOICE

1. The nurse understands the need for accurate documentation due to which fact?
a. Accurate documentation is needed for proper reimbursement.
b. Accurate documentation must be electronically generated.
c. Accurate documentation does not include e-mails or faxes.
d. Accurate documentation is only accepted in court if written by hand.
ANS: A
Accurate documentation is necessary for hospitals to be reimbursed according to diagnostic-
related groups (DRGs). DRGs are a system used to classify hospital admissions. Health care
documentation is any written or electronically generated information about a patient that
describes the patient, the patient’s health, and the care and services provided, including the
dates of care. These records may be paper or electronic documents, such as electronic medical
records, faxes, e-mails, audiotapes, videotapes, and images. All such records are considered
legal documentation and may be used in court.

DIF: Remembering OBJ: 10.1 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication

2. The nurse identifies which statement to be true regarding nursing documentation?
a. Standards for documentation are established by a national commission.
b. Medical records should be accessible to everyone.
c. Documentation should not include the patient’s diagnosis.
d. High-quality nursing documentation reflects the nursing process.
ANS: D
The ANA’s model for high-quality nursing documentation reflects the nursing process and
includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and
retrievability. Standards for documentation are established by each health care organization’s
policies and procedures. They should be in agreement with The Joint Commission’s standards
and elements of performance, including having a medical record for each patient that is
accessed only by authorized personnel. General principles of medical record documentation
from the Centers for Medicare and Medicaid Services (2017) include the need for
completeness and legibility; the reasons for each patient encounter, including assessments and
diagnosis; and the plan of care, the patient’s progress, and any changes in diagnosis and
treatment.

DIF: Understanding OBJ: 10.1 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication

3. The nurse identifies which true statement regarding the medical record?
a. It serves as a major communication tool but is not a legal document.
b. It cannot be used to assess quality of care issues.

Downloaded
Downloaded
by: LuckyGrades
by: Sophiie
SuperA ||abiekay12@gmail.com
abbiewamalwa@gmail.com
Distribution of this document is illegal

, Stuvia.com - The Marketplace to Buy and Sell your Study Material

c. It is not used to determine reimbursement claims.
d. It can be used as a tool for biomedical research and provide education.
ANS: D
The medical record promotes continuity of care and ensures that patients receive appropriate
health care services. The record can be used to assess quality-of-care measures, determine the
medical necessity of health care services, support reimbursement claims, and protect health
care providers, patients, and others in legal matters. It is a clinical data archive. The medical
record serves as a tool for biomedical research and provider education, collection of statistical
data for government and other agencies, maintenance of compliance with external regulatory
bodies, and establishment of policies and regulations for standards of care. The record serves
as the major communication tool between staff members and as a single data access point for
everyone involved in the patient’s care. It is a legal document that must meet guidelines for
completeness, accuracy, timeliness, accessibility, and authenticity. The record can be used to
assess quality-of-care measures, determine the medical necessity of health care services,
support reimbursement claims, and protect health care providers, patients, and others in legal
matters.

DIF: Understanding OBJ: 10.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication

4. The nurse knows that paper records are being replaced by other forms of record keeping for
what reason?
a.Paper is fragile and susceptible to damage.
b.Paper records are always available to multiple people at a time.
c.Paper records can be stored without difficulty and are easily retrievable.
d.Paper records are permanent and last indefinitely.
ANS: A
Paper records have several potential problems. Paper is fragile, susceptible to damage, and can
degrade over time. It may be difficult to locate a particular chart because it is being used by
someone else, it is in a different department, or it is misfiled. Storage and control of paper
records can be a major problem.

DIF: Evaluating OBJ: 10.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication

5. When the nurse is charting in the paper medical record, what action does the nurse carry out?
a. Print his/her name since signatures are often not readable.
b. Omit nursing credentials since only the nurses chart
c. Skip a line between entries so that it looks neat.
d. Use black ink unless the facility allows a different color.
ANS: D
Entries into paper medical records are traditionally made with black ink to enable copying or
scanning, unless a facility requires or allows a different color. The date, time, and signature,
with credentials of the person writing the entry, are included in the entry. No blank spaces are
left between entries because they could allow someone to add a note out of sequence.

DIF: Remembering OBJ: 10.3 TOP: Implementation

Downloaded
Downloaded
by: LuckyGrades
by: Sophiie
SuperA ||abiekay12@gmail.com
abbiewamalwa@gmail.com
Distribution of this document is illegal

, Stuvia.com - The Marketplace to Buy and Sell your Study Material

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication

6. The nurse is admitting a patient who has had several previous admissions. To obtain a
knowledge base about the patient’s medical history, the nurse would access which document?
a. Electronic medical record (EMR)
b. The computerized provider order entry (CPOE)
c. Electronic health record (EHR)
d. Primary provider’s office notes
ANS: C
The EHR is a longitudinal record of health that includes the information from inpatient and
outpatient episodes of health care from one or more care settings. The EMR is a record of one
episode of care, such as an inpatient stay or an outpatient appointment. CPOE allows
clinicians to enter orders in a computer that are sent directly to the appropriate department. It
does not provide historical data. The primary provider’s office notes may not include all the
patient’s information if the patient has other providers.

DIF: Applying OBJ: 10.2 TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication

7. The nurse understands which statement about the use of electronic health records is true?
a. They improve patient health status.
b. They require a keyboard to enter data.
c. They have not reduced medication errors.
d. They require increased storage space.
ANS: A
Adoption of an EHR system produces major cost savings through gains in productivity and
error reduction, which ultimately improves patient health status. The most common benefits of
electronic records are increased delivery of guideline-based care, better monitoring, reduced
medication errors, and decreased use of care. Use of EHRs can reduce storage space, allow
simultaneous access by multiple users, facilitate easy duplication for sharing or backup, and
increase portability in environments using wireless systems and hand-held devices. Although
data are often entered by keyboard, they can also be entered by means of dictated voice
recordings, light pens, or handwriting and pattern recognition systems.

DIF: Remembering OBJ: 10.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication

8. The nurse is caring for patients on a unit that uses electronic health records (EHRs). What
action by the nurse protects personal health information?
a. The nurse should allow only nurses that he/she knows and trusts to use his/her
verification code.
b. The nurse should not worry about mistakes since the information cannot be
tracked.
c. The nurse should never share any password with anyone.
d. The nurse should be aware that the EHR is sophisticated and immune to failure.
ANS: C

Downloaded
Downloaded
by: LuckyGrades
by: Sophiie
SuperA ||abiekay12@gmail.com
abbiewamalwa@gmail.com
Distribution of this document is illegal

The benefits of buying summaries with Stuvia:

Guaranteed quality through customer reviews

Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.

Quick and easy check-out

You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.

Focus on what matters

Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!

Frequently asked questions

What do I get when I buy this document?

You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.

Satisfaction guarantee: how does it work?

Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.

Who am I buying these notes from?

Stuvia is a marketplace, so you are not buying this document from us, but from seller Lectfayh. Stuvia facilitates payment to the seller.

Will I be stuck with a subscription?

No, you only buy these notes for CA$28.22. You're not tied to anything after your purchase.

Can Stuvia be trusted?

4.6 stars on Google & Trustpilot (+1000 reviews)

78252 documents were sold in the last 30 days

Founded in 2010, the go-to place to buy study notes for 14 years now

Start selling

Exam (elaborations)

Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative Practice, 2nd Edition Test Bank All Chapters

Document information

Subjects

Connected book

More summaries for

Written for

Seller

Reviews received

Content preview