Nur-100 Foundations of Nursing Final Exam, Answered-A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult
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Nur-100 Foundations of Nursing Final Exam, Answered-A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information?
1. "Avoid rushing when documenting an entry in the medical record."
2. "Use correction fluid to remove the entry."
3. " Draw a single line through the statement and initial it."
4. Enter only objective and factual info about a patient in the medical record
- 4- Nurses should enter only objective and factual info about patients. Opinions have no place in the medical record. Because the info has already been entered and is no incorrect, it should be left on the record
A preceptor observes a new graduate nurse discussing changes in a patient's conditions with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some lab tests from the physician at the end of the conversation. During the conversation the new grad writes the orders on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene?
1. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone
2. Documents the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record
3. Gives a newly ordered medication before entering the order in the patient's medical record
4. Asks the preceptor to listen in on the phone conversation
- 3- When provider orders for new medications are entered into an electronic medical record, the new orders are available to pharmacists using the same electronic system within the hospital. To improve patient safety, many hospitals have a policy that new medications are not to be administered until a pharmacist reviews the new orders, and verifies that there is no document allergies to the medications, the ordered doses are appropriate, and that there are no potential medication interactions with medications already ordered for a patient. Nurse enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur
As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, " I don't know what's going on: I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this observation of he patient?
1. "The patient has a defiant attitude and is demanding test results."
2. "The patient appears to be upset with the nurse because he wants his test results immediately."
3. "The patient is demanding and is complaining about the doctor."
4. "The patient stated feelings of frustration from the lack of info received regarding test results."
- 4- This is a nonjudgmental statement regarding the nurse's observations about the patient. Documenting that the patient has a defiant attitude or is demanding is judgmental, and info in the medical record should be factual and nonjudgmental. Noting that the patient appears upset with the nurse needs to be more specific; it does not provide enough info regarding the reason for the patient's concerns
The nurse is reviewing the HIPAA regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response?
1. HIPAA allows hospital staff access to your medical record
2. HIPAA limits the info that is documented in your medical record
3. HIPAA provides you with greater protection of you personal health info
4. HIPAA enables health care institutions to release all of your personal info to improve continuity of care
- 3- HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patien'ts medical record
A patient states, "I would like to see what is written in my medical record." What is the nurse's best response?
1. "Only your family can read your medical record"
2. "You have the right to read your record"
3. "Patient's are not allowed to read their records"
4. "Only health care workers have access to patient records"
- 2- Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission
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