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EXAM: Documentation and Informatics EAQ: Questions with Complete Solutions $11.99   Add to cart

Exam (elaborations)

EXAM: Documentation and Informatics EAQ: Questions with Complete Solutions

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EXAM: Documentation and Informatics EAQ: Questions with Complete Solutions enter only objective and subjective information CORRECT ANS-A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "The patient is difficult to care for and refuses sugge...

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  • September 1, 2024
  • 9
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • EAQ
  • EAQ
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TheeGrades
EXAM: Documentation and Informatics EAQ:
Questions with Complete Solutions
enter only objective and subjective information CORRECT ANS-A manager who is

reviewing the nurses' notes in a patient's medical record finds the following entry, "The

patient is difficult to care for and refuses suggestions for improving appetite." Which

directions does the manager give to the staff nurse who entered the note?




oral communication and written reports CORRECT ANS-Communication among the

members of a healthcare team is essential to providing quality care to patients. Which are the

modes for exchanging information among the members of the healthcare team?




hand off report CORRECT ANS-At the end of a shift, the nurse documents a patient's

condition, anticipated condition, medications, and nursing interventions fulfilled so that the

next nurse can follow the appropriate treatment plan and care for the patient. What is this

kind of report?




the patients incision site looks clean without any purulent drainage or erythema CORRECT

ANS-The nurse assesses a patient on day 3 after surgery and charts a progress note in the

SOAP (subjective data, objective data, assessment, and plan) format. Which is considered an

objective datum?

, EXAM: Documentation and Informatics EAQ:
Questions with Complete Solutions
you need to use words that the patients understand when writing a teaching sheet

CORRECT ANS-You are helping to design a new teaching sheet that will go home with

patients who are discharged home from your unit. Which option do you need to remember

when designing the teaching sheet?




HIPPA CORRECT ANS-The nurse faxes a patient's medical record to an unknown number.

Which law is the nurse violating?




transfer reports CORRECT ANS-A patient was shifted from the intensive care unit to the

cardiac unit. What kinds of reports are used to communicate between the two units?




integrates all pertinent patient information into one record, performs checks to support

regulatory requirements, provides the means to compare ongoing clinical data with baseline

information CORRECT ANS-The nurse is giving information to a group of caregivers about

electronic health records (EHRs). What information about the EHR should the nurse offer

them?

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