A charge nurse is providing an in-service on documentation with a group of staff nurses. Which of the following should the nurse include as a component of an electronic health record?

Demographic data

Billing payments

Driver's license

Facility policies

Answer and Explanation

The Correct Answer is A

A. Demographic data. An electronic health record (EHR) includes demographic information such as the client’s name, date of birth, contact details, and medical history. This data helps healthcare providers personalize care and ensure accurate record-keeping.

B. Billing payments. While healthcare facilities may have electronic billing systems, financial transactions and payments are not considered a core component of the EHR, which primarily focuses on clinical documentation and patient care.

C. Driver's license. A driver's license may be used for identity verification during registration, but it is not a required component of an EHR. Identifying information is documented separately from clinical records.

D. Facility policies. EHRs store patient-related health information rather than institutional policies. Facility policies are typically maintained in administrative systems or policy manuals, separate from patient medical records.

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Correct Answer is A

Explanation

A. Managing knowledge. Nursing informatics involves using information technology to collect, store, analyze, and share knowledge to enhance patient care, improve decision-making, and streamline healthcare processes. This aligns with the primary function of informatics in healthcare.

B. Producing clinical pathways. While informatics can support the development of clinical pathways by analyzing data and trends, its primary purpose is broader—focusing on knowledge management and improving healthcare efficiency rather than just pathway development.

C. Providing a safe place to provide care. Informatics contributes to safety through tools such as electronic health records (EHRs) and clinical decision support systems, but it does not directly create a physical safe space for patient care.

D. Preventing burnout. Informatics can help reduce workload and streamline documentation, potentially lowering stress levels for healthcare providers. However, its main function is to manage knowledge and improve patient care through the use of technology.

A. Decrease in coordination of client care B. Increase of duplicate tests performed on client C. Portal that allows clients to interact with providers D. Same day access to client health record

Correct Answer is C

Explanation

A. Decrease in coordination of client care. Electronic documentation improves, rather than decreases, coordination of care by allowing multiple healthcare providers to access real-time patient information, reducing communication errors and delays.

B. Increase of duplicate tests performed on client. Electronic health records (EHRs) help minimize duplicate testing by providing a comprehensive view of a client’s medical history, including previous tests and results, thereby reducing unnecessary procedures.

C. Portal that allows clients to interact with providers. Many electronic documentation systems include patient portals, enabling clients to schedule appointments, view test results, communicate with providers, and access educational resources, which enhances patient engagement and healthcare transparency.

D. Same-day access to client health record. While EHRs improve accessibility, updates to a client’s health record may depend on documentation workflow and provider input. Some results, such as lab tests, may not be immediately available, making this statement less universally accurate.

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A charge nurse is providing an in-service on documentation with a group of staff nurses. Which of the following should the nurse include as a component of an electronic health record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing informatics with a newly licensed nurse. The nurse identifies that informatics is defined as the use of information and technology for which of the following?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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